Truth Telling as an Element of Ethical Behaviour and Professional Commitment in Dentistry: A Case Study Assessing Non-Disclosure Action

Truth Telling as an Element of Ethical Behaviour and Professional Commitment in Dentistry: A Case Study Assessing Non-Disclosure Action. abstract Being truthful with patients is a critical foundation of the doctor-patient relationship and is fundamental to development of trust. A professional commitment to truth telling may sometimes contradict other principles of bioethics, which may challenge decision-making for the doctor and/or the treatment team. Practitioners may fail to address all ethical or legal aspects of a case and therefore make inappropriate decisions. Résumé Abstract Dire la vérité aux patients est un fondement essentiel de la relation médecin-patient et est indispensable au développement de la confiance. Un engagement professionnel à dire la vérité peut parfois contredire d’autres principes de bioéthique, ce qui peut remettre en question la prise de décision du médecin ou de l’équipe traitant. Les praticiens peuvent ne pas aborder tous les aspects éthiques ou juridiques d’un cas et donc prendre des décisions inappropriées. Being truthful with patients is a critical foundation of the doctor- patient relationship and is fundamental to development of trust. A professional commitment to truth telling may sometimes contradict other principles of bioethics, which may challenge decision-making for the doctor and/or the treatment team. Practitioners may fail to address all ethical or legal aspects of a case and therefore make inappropriate decisions. Mots-clés


INTRODUCTION
Adherence to ethical precepts embodies conduct expected of health care professionals. In modern bioethics, the concept of patient preference or autonomy is considered a principle of evidence-based care (1). Indeed, it is a major focal point in practitioner-patient relationships in comparison with the older paternalistic approach (2). As a result, the patient's contribution to their treatment options and choices has been emphasised and is represented through the process of obtaining informed consent. To accomplish the latter, it is crucial to provide relevant, accurate and understandable information to the patient to facilitate decision-making. Truthfulness as a component of medical professionalism is a basic tenet that supports patient autonomy, beneficence (positive benefit) and non-maleficence (do not harm). However, disclosing truth may be considered challenging in situations involving distressing news such as life-threatening diagnoses. Additionally, there may be situations where truth telling contradicts beneficence and/or non-maleficence (3,4).
Practitioners may elect not to disclose all information to patients or perhaps offer such information in a less than transparent manner especially when discussing serious medical conditions. This may occur intentionally in an effort to preserve a patient's positive outlook, or it may simply be due to lack of experience, skills, and confidence (5,6). A review of the following case study may help clinicians recognize such situations and develop the skills required to manage such circumstances. In the case discussed below, which was managed by one of the authors (LS), we show that despite the aspiration for adherence to several underlying ethical obligations, the practitioner must be able to appreciate the patient's vulnerability and desire to fully comprehend the current medical reality in the context of a particular family dynamic.

A CASE STUDY: MIDDLE EASTERN MAN WITH CHONDROSARCOMA
A 65-year-old self-employed man had come to a dental clinic for implant-supported overdenture treatment. He has a history of two surgical procedures for a jaw joint cartilage malignant tumor (chondrosarcoma), including partial ablation/resection of the lower jawbone (Fig. 1). Having experienced a prior recurrence of the tumor, he is very afraid of another. The oncologist had opined that the risk was not very high. The patient therefore received his physician's approval for dental implant treatment to proceed. During treatment, the dentist noticed a temporal swelling adjacent to the previous surgical site. The patient's children privately asked the dentist not to disclose any information about the disease to him, because their father had recently recovered emotionally and knowing about a recurrence would distress him greatly. Additionally, thinking that the dentist might be reluctant to proceed with treatment based on the costs to their father, the children assured the dentist that he had paid for part of the treatment and would pay the rest when the denture was delivered.

Figure1. Patient with hemimandiblectomy with titanium chain reconstruction and two dental implants
Source: L Sadighpour, with patient's consent

ETHICAL ANALYSIS
In the current scenario, several considerations may discourage the dentist from telling the truth about the possibility of tumor recurrence, including the patient's mental state and related fear, his children's request, and concern that the patient may not return for his follow-up treatment. The latter may result in delayed treatment and/or non-payment of fees. However, the decision to withhold information or to resist complete disclosure could violate both respect for autonomy and the professional obligation to inform the patient about his health and treatment. An appropriate approach to such issues requires consideration of different factors, such as the nature of the disease, the patient's social, mental, and economic status, the patient's quality of life, and the social-cultural background. Hence, the dentist must justify a non-disclosure decision, should this be the case (7). The reasons presented for not revealing the truth usually follow the principle of "non-maleficence", and they include consideration of the emotional, mental, or physical capacity of the patient to cope with the truth about their disease (5,7,8).
In the present case, the children's wish to preserve hope may be a significant factor motivating the dentist toward a deceptive action. Generally speaking, if the practitioner is convinced that deception is a better option for the patient, perhaps other alternatives may first be sought (7). This may include indirect (or ambiguous) statements. For example, in this case, the dentist must consider their professional responsibility to refer the patient to the oncology surgeon for treatment. This would potentially distress the patient and prompt him to ask further questions. In order to implement so called "non-lying deception", appropriate statements can be practiced beforehand to convey a cautious, and "opaque" response. For instance, "I can modify your implant-supported dentures, depending on what your surgeon decides, so I'd like to consult with him before we proceed". In this way, the response is carefully balanced between concealing the entire truth and providing a more limited explanation. If practitioners must contend with the potentially uncomfortable non-disclosure approach, it must be understood that nondisclosure is usually not a desirable option -it would be prudent for the practitioner to carefully consider all reasonable alternatives. It follows that the doctor is required to exercise extremely careful judgment in balancing the reasons for and against full disclosure. If justification of deception outweighs objections, the doctor must then consider how to defend the decision and their reasoning before professional colleagues, a regulatory authority, "the court of public opinion," and even their own conscience (7). In the present scenario, and despite the children's assertions, the doctor was uncertain about the patient's preference for non-disclosure and decided to contact the oncology surgeon for more information about the disease and the significance of the new temporal swelling. Before referring the patient to the surgeon, a meeting was arranged with the patient's family to review the implication(s) and/or necessity of disclosure as well as to inquire about the family relationship relative to care-giving. It was influenced by the importance of the family's role in decision-making in Eastern country culture where the elderly are taken care of by their families (8,9).

CONCLUSION
Whether discussing adverse events, admitting to errors, or conveying bad news, health care professionals have an obligation of honesty and transparency in their communication with patients. This can nonetheless be challenging as it requires an element of self-reflection, preparation, and sensitivity. An additional aspect in this case was the fact that a doctor's approach to and the society's expectation toward truth-telling, especially when it is associated with a great emotional burden, are different in Eastern and Western countries. In many jurisdictions, there is a legal requirement to obtain patient consent prior to revealing any information about the patient's health information to any third party. However, in certain Eastern societies, the family plays a key role in decision-making, especially when the elder has serious disease and are looked after by the family. Therefore, in critical situations, the family plays an important role in decision-making, often a more significant role than the patient themselves. Such a case may have several outcomes, which ultimately results from how certain difficult questions are answered, including: The editors follow the recommendations and procedures outlined in the COPE Code of Conduct and Best Practice Guidelines for Journal Editors. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal's standards of excellence.