Conflicts and Challenges of Truth-Telling in Dentistry: A Case-Based Ethical Analysis.

Objectives : The basis of truth-telling is respecting the autonomy of patients and developing an ability to make informed decisions with valid consent. The purpose of this study was to ethically analyze the conflicts about truth-telling in dentistry. Materials and
Methods: This case analysis focused on the issues of truth-telling in medicine and dentistry. The challenges encountered by dentists with respect to ethical issues related to truth-telling were discussed and analyzed by the research team.
Results: The literature review showed that the issue of truth-telling in dentistry has been addressed from three aspects: Truth-telling about other dentists' medical errors, truth-telling about dangerous, refractory, or incurable diseases, and truth-telling to children or incompetent individuals for decision-making.
Conclusion: When the duty of the dentist in truth-telling is conflicted with some other moral obligations, the conflict between the prima facie duties arises. The principle-based ethical theories provide a suitable conceptual framework for moral judgement in such conflicts. In cases of conflicts related to truth-telling, a balance should be maintained between principles and rules such as fidelity, respect for autonomy, maintaining trust in dentist-patient relation, and best interest of patients. The decision in truth-telling should be made individually for each patient based on the specific contextual conditions.

Introduction

Truth denotes the real facts about a situation, event, or person [1]. Veracity in healthcare refers to accurate, timely, objective, and detailed expression of information, and the skills used by the physicians to enhance the patients’ understanding [2].

There is a universal consensus on accepting truth-telling as an ethical rule [3]. Truth-telling is a general moral norm that has been emphasized in various religions, philosophical schools, and cultures. There is no direct reference to the physicians’ moral obligations to tell the truth to patients in well-known traditional medical ethics texts such as Hippocratic Oath or the Declaration of Geneva [4]. However, this lack of direct reference to the truth-telling does not mean that this principle of medical professional ethics was overlooked by the ancients. For instance, the Hippocratic Oath offers two pivotal virtues of purity and holiness for physicians, and a person with such virtues will predominantly adhere to truth-telling.

Ignoring the truth-telling can somewhat be attributed to the paternalistic tradition that allows physicians virtually unlimited discretion about what to divulge to patients particularly in some conflicts [5], such that Hippocrates advised to conceal most things from the patients and give them required orders with cheerfulness and serenity [6]. Such an approach is also stated in Thomas Percival's Code of Ethics, which states that to provide healthcare to patients and keep their hope up in stressful conditions and adverse events, physicians must adhere to the Hippocratic paternalism and conceal the information of patients [5]. The ethical codes of the American Medical Association also advise physicians to be meticulous and sharp-witted in telling bad news to patients [7]. This idea was reflected in their medical ethics guideline as "The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician". Thus, physicians should be cautious in their interactions with patients and avoid actions and behaviors that cause discouragement and depression [6]. Despite this traditional approach to medical ethics, the ethical principle of truth-telling has been a commendable characteristic. The history of the truth-telling principle reflects a shift in the professional ethics approach to the issue, as further revisions to the American Medical Association ethics recommend that physicians take an honest approach to the patient and colleagues [8].

For a professional dentist, truth-telling in daily practice should be a priority. But sometimes it seems that it is not possible due to some conflicts. Although in some cases withholding the truth may be less unethical than lying, it cannot be generalized.

The manner of truth-telling and expressing facts varies in different cultures and societies depending on the patients' physical and psychological conditions. Various social and personal factors affect the physicians’ decision about the extent and manner of providing information to patients. For example, cultural, religious, social, and ethnic traditions are among the influential social factors [2], and personal factors, disease conditions, psychological and emotional characteristics, religious affiliations, and family relationships are among the influential personal factors affecting the extent of truth-telling in practice and reality. The supremacy of the principle of autonomy and informed consent seems to have made it acceptable to tell the truth to patients in Western societies; but in many eastern societies, due to the prevailing conditions, and based on the principle of non-maleficence, concealing the truth about disease in some cases is more common and, in some cases, treatment is provided while the patient is unaware of the exact nature of the disease [9-11]. Patients nowadays increasingly believe in their right to have information about their health and ask the physicians to inform them about their diagnosis and treatment. As previously emphasized, patients are eager to know the truth about their disease [12] and ask for disclosure of all errors and seek information about what and why errors happened and how to mitigate the consequences [13]. In medical and dental ethics today, there are conflicts and questions about truth-telling to patients. Principle-based ethics is the appropriate conceptual framework for ethical evaluation of these conflicts. This framework, based on the ethical theory of "a prima facie duty," can help achieve appropriate responses in moral conflicts. “At first glance,” truth-telling is a prima facie duty that appears to be what professionals should do without considering any other factors, but actual or real duty is only one morally justified duty in any situation; however, the actual duty may not always be obvious, particularly when duties conflict (14). Numerous articles have been published on truth-telling in the medical field, but in dentistry, we found a knowledge gap in this respect. Due to its importance, this study aimed to analyze the facts and challenges of truth-telling in dentistry and the barriers against its implementation. Three main challenges in dentistry related to truth-telling were defined:

Truth-telling about other dentists’ medical errors

Truth-telling about dangerous, refractory, or incurable diseases

Truth-telling to children or incompetent persons for decision-making

we laid out three clinical dental case scenarios that call for a professional behavior. The ethical issues explored using three case studies are presented.

MATERIALS AND METHODS

This study was a case-based ethical analysis. Various databases were searched from 1990 to 2021. The searched keywords were “truth-telling” OR “veracity” OR “honesty” AND “dent”. A total of 76 articles were found in the initial results, 9 of which were related to truth-telling according to their titles and abstracts. To enrich the content, 6 of most cited codes of dental ethics were also included in this review, developed by various dental associations. Through the content of articles and codes, three main challenges in dentistry related to truth-telling were defined by the research team.

Finally, these three category of cases were analyzed by using a case-based ethical analysis, which is a standard approach of balancing and specification of professional norms including ethical principles, rules, rights, and moral obligations.

Results

Ethical cases raised by the literature review are shown in Table 1.

Table 1

Clinical ethical cases

Case 1	Truth-telling about other dentists’ medical errors: A patient presents with constant pain under prosthetic crown of first molar tooth, and after examination, the dentist tells the patient that the respective tooth has no problem and its root canal treatment has been performed in accordance with the scientific principles. Due to the lack of accountability of the first dentist, the patient visits a second dentist and after radiographic examination, the second dentist finds out that the root canal treatment of the respective tooth is incomplete and that pulpitis may be the cause of pain. What should the second dentist do when observing a colleague's error and asked by the patient for guidance?
Case 2	Truth-telling about dangerous, refractory, or incurable diseases: A 48-year-old male patient presents to a dentist for periodontal surgery of his tooth with a class 3 mobility according to the Miller’s Classification. There is a suspicious wound at the site. The dentist says that the definitive diagnosis depends on the biopsy and the pathology report. The patient's spouse secretly asks the dentist to perform a biopsy under periodontal surgery, and if a cancer diagnosis is reported, the patient should not be informed because of his depressive disorder. What should be the dentist’s response to this demand about not telling the truth to patient?
Case 3	Truth-telling to children or incompetent persons for decision-making: Extraction of primary first molar should be performed for a 6-year-old. At first, the child asks the dentist about the action that is about to be carried out. While keeping the truth, the dentist distracts the child and at the same time without showing the syringe skillfully performs the anesthetic injection. The child does not like the strange feeling of numbness and the bad taste of the anesthetic agent and asks again about the procedure but does not receive any answer.

Errors are common in the healthcare system. The error and its origin must be timely identified, and the extent of the injury must be told and discussed with the patient and its compensation should be managed and pursued [15].

Dentists easily evaluate the practice of their colleagues, but it is important to distinguish an ordinary mishap from a real mistake caused by incompetence. The arguments for and against are listed in Table 2.

Table 2

Arguments for and against truth-telling about a colleague's error

Arguments in favor of giving priority to truth-telling:	Arguments against giving priority to truth-telling:
Patient should follow the therapeutic procedures [ 3 ].	The patient's awareness causes stress, anxiety, and confusion [16].
Patient has the right to know the truth about his/her disease and diagnostic and therapeutic procedures [ 3 , 19 ].	Feeling frustrated and experiencing distrust in dentist-patient relationship [21]
Reduction of legal liability of the dentist [ 20 ]	Decreased patient flow due to doubt in the dentist 's clinical skills
Learning from the past mistakes	Possible patient complaints [16]
Possibility of patient injury compensation [ 16 ]
The dentist feels more comfortable in truth-telling [21]
Hiding a colleague's error is a type of collusion [ 2 ]

Careful consideration should be given to whether the procedure has been performed incorrectly or a bad result has been obtained. Judgment cannot be made based on the evidence provided by the patient. In any event, the patient's anger and mistrust about the first dentist should not be aggravated. Probabilities, predictions, and assumptions should be avoided because the patient considers the worst case scenario. Based on the duty of self-regulation, the second dentist must talk to the first dentist to disclose the error to the patient and compensate any harm caused by his/her error as soon as possible according to the existing regulations [16]. The disclosure of medical error is a subset of provision of bad news, but it is more difficult to make such disclosures because clinicians that cause the harm subsequently fear of malpractice suits.

The Professional Ethics Guide for the Iranian medical professionals regarding the harms to patients due to the mistakes of colleagues stipulates that the colleagues' professional status and dignity should be preserved and the patient should be guided whilst avoiding any non-expert judgment and comment [17].

“Professional dentists should avoid any judgment in encounters with patients and explain only the current problem and treatment solutions and should not comment on the dental practice of other colleagues and leave the matter to the relevant authorities” [22]. If the patient does not intend to continue treatment with the first dentist and a relationship with the second dentist is established, complete disclosure of information must be made for the benefit of the patient, and then appropriate treatment should be provided [17,20]. Using an intraoral camera and pointing to a mistake will help the patient gain confidence, because people trust what they see and feel better about seeing than hearing [23]. Although ethics states that colleagues must be treated fairly, in case the error significantly affects the patient's health, the error must be disclosed and its significance must be explained to the patient to prevent further damage, and the argument about patient's distrust cannot override this important ethical principle. In this situation, respecting the patient’s autonomy was violated. It should be noted that only the legal authority has the right to investigate the case and determine the potential compensations. Due to the dentist's inattention to endodontic periapical lesion, it seems that the second dentist needs to adopt an appropriate intervention for endodontic treatment. Of course, the best way is to communicate with the colleague and convince him to correct the error. If it is not possible, it is necessary to explain the current condition and convince the patient for endodontic retreatment. It is not necessary to provide too much information in revealing the truth more than what is needed to obtain an informed consent.

If the patient files a lawsuit, the first dentist must admit his/her mistake to the relevant legal authorities in the medical council.

Case 2. Truth-telling about dangerous, refractory, or incurable diseases

The dentist is faced with the following ethical dilemma:

According to the principle of autonomy, the patient has the right to know the truth about his/her disease.

According to the principle of non-maleficence and putting the patient’s interest first, the truth should not be told to the patient.

There is a possibility that telling the truth can cause emotional reactions in the patient and worsen the prognosis or probably lead to hopelessness and suicide. Thus, concealment of part of the truth may be acceptable, but it cannot be predicted whether revealing or concealing the truth would be more beneficial in the end [2].

The impact of truth-telling on the quality or quantity of a patient's life cannot be measured [24,25]. Regardless of how and when to tell the truth to the patient based on his/her circumstances, the dentist must first ensure that the patient is fully aware of the truth of his/her illness. Ethical guidelines (e.g. SPIKES) also recommend flexibility with regard to the patient's emotions, and when and how to express sensitive facts, particularly bad news [24]. The arguments for and against are listed in Table 3.

Table 3

Arguments for and against truth-telling about dangerous diseases

Arguments in favor of giving priority to truth-telling:	Arguments against giving priority to truth-telling:
Truth-telling is a virtue [ 3 , 19 ]	Dentist's benevolent intention to benefit and not harm the patient
Truth-telling is essential for the development and maintenance of trust in physician-patient relationship [ 2 , 3 ].	Possibility of inflicting psychological trauma to a patient when hearing the truth
Truth-telling is a moral and legal duty [ 3 ].	Truth-telling is not always the best policy [29].
Sign of fidelity and promise-keeping in contract [ 2 ]	Truth-telling is not absolute [2,29].
Patient has the right to know the truth (although bitter) [ 26 ]	According to the Hippocrates Oath to primum non nocere (or first do no harm) [3]
Respect for human dignity and respect for patient autonomy [ 18 ]	Benevolent intention to help the patient and avoid the risk of life and suicide [27]
The need for patient participation in critical decisions and treatment choices [ 18 ]	Possibility of patient's disappointment and abandonment of treatment
Patient's ability to make informed decisions [ 18 ]	Limitations of medical science and uncertainty due to the complexities of diagnosis, prognosis, and side effects of the disease [3]
Realization of therapeutic goals and benefiting patients [ 3 ]	Lack of skills of the medical team in delivering bad news [18]
Patient's collaboration and consent to treatment [ 27 ]	The family requests withholding the diagnosis from a patient
Concealing the truth confuses the patient and results in his/her ambiguity [ 28 ].	Not to cause worries, anxiety, and depression
Concealing the truth results in patient's failure to follow up on treatment and causes irreparable injuries [ 3 , 28 ].	By providing information (e.g. a rare complication of a drug), the patient becomes more confused and refuses to accept effective treatment [10].
Concealing the truth causes irreparable consequences for the physician [ 3 , 28 ].	The therapeutic privilege permits dentists to withhold information.
The patient expects a truthful response from the physician [ 26 ].	The patient's waiver to know the truth
Sooner or later the truth will be revealed. Coincidental and awkward discovery of the truth will be more harmful to the patient [ 27 , 28 ].
Poor judgment of the physician in predicting the patient's fears [ 3 ]
The patient wants to make an end-of-life planning [ 27 ].

Ultimately, it is the art of the dentist to identify the patient's expectations, information preferences, and needs by establishing a genuine and honest relationship with the patient and to select the best way to express the patient's treatment choices. In so doing, the rule of law is enacted, ethics and the autonomy of the patient are respected, and the beneficence and non-maleficence are not ignored [30]. ‘’Professional dentists should not deceive patients regarding the extent and severity of the disease and should not indulge their patients in false hopes’’ [22]. In this case, the patient's spouse must be informed of the dentist’s duty to provide the patient with sufficient information to make an appropriate decision. Disclosure of information by the dentist at an appropriate time and with special considerations can reduce the patient's stress, while accidental and uncontrolled information can disrupt the trust in the relationship, and is also more harmful to the patient.

Case 3. Truth-telling to children or incompetent persons for decision-making

The dentist is faced with the following ethical dilemma:

To maintain trust in the dentist, the truth must be told to the child.

The truth should not be told to the child based on the principle of beneficence and obtaining children's cooperation.

Unlike adults, kids tend to see things as black and white, and people are either trustworthy or not. Honesty or candor is important to build trust between the dentist and the child, and is a fundamental principle in child care. Dentists should have the best interest of the child in mind with the consent of his/her surrogate. Of course, this does not mean ignoring the desires of the child. The child's wishes should be considered as long as the interests of the child are not compromised. Dentists are committed to honesty by explaining the procedure according to the child's level of understanding [31].

No ethical code of dentistry deals directly with truth-telling to children or incompetent persons. the Charter of Patients' Rights in Iran states that if the patient lacks sufficient capacity to make decisions, but can reasonably participate in some parts of the decision making process, their decision must be respected [19] and the first condition for respecting their decision is to observe the truth-telling principle. The arguments for and against are listed in Table 4.

Table 4

Arguments for and against truth-telling to children

Arguments in favor of giving priority to truth-telling:	Arguments against giving priority to truth-telling:
Maintaining the child's trust in the dentist	Obtaining children's cooperation and continuing the procedure
Failure to tell the truth causes long-term negative psychological consequences in the child.	The child does not have the mental capacity to understand the necessity and importance of the procedure.
Failure to tell the truth teaches the child to lie	Considering the child's current interests
Failure to tell the truth betrays the child's trust [ 31 ].

The dentist cannot resort to lying for the immediate interest of the child because his/her trust in the dentist would be destroyed. It is best to describe the process in a timely and calm manner to the child in a simple language. Some information can be delayed and spread over a period of time.

Dentist may want to postpone treatment to another session if the child is not ready. Methods of sedation or anesthesia may be used if the patient has poor cooperation. Professional dentists should establish effective communication with their patients and make every effort to support vulnerable patients [22].

CONCLUSION

Truth-telling is an important rule and a virtuous act that is closely related to respect for autonomy and ranks in importance with beneficence and non-maleficence in contemporary bioethics. Although it is ethically accepted that dentists should always adhere to truth-telling, in daily practice of dentistry, they may fail to do so because of factors such as fear of legal reprisals or fear of causing psychological harm to the patient. The principle-based ethics is an appropriate conceptual framework for ethical evaluation. Truth-telling consists of subjective and objective components that act in a dynamic, mutual process between the dentist and the patient. Providing the patient with accurate information about the situation allows the patient to make an informed decision and is considered as respecting the patient’s dignity. Truth-telling is a prima facie duty for dentists but telling the truth is not a static act, it is a dynamic process. Dentists should have specific instructions for each patient and make decisions about the manner of truth-telling based on experience, knowledge, help from colleagues, and cooperation of the patient's family and companions.