In the cases in chapter 8, dentists faced the problem of whether to respect the autonomous choices of patients, especially when the dentists had reason to believe that their patients would be better off if patient autonomy was violated. Informed consent is increasingly grounded on the moral principle of autonomy. While autonomy is a significant part of the notion of respect for persons, there are other dimensions as well. One is the ethical principle of veracity, or truth-telling. The cases in this chapter examine the ethics of dealing honestly with patients.
Often dishonesty turns out to make no sense for the dishonest person or for anyone else. The liar destroys his or her reputation; the lie is self-defeating. The dentist who consistently lies to his or her own advantage will be found out. There are special cases, however, when it is morally debatable whether an exception might be made in situations where a lie or a shading of the truth could be justified because of the benefits to the patient. In these cases the question is whether the clinician should continue to pursue the patient’s welfare or should deal honestly with the patient even if the patient will be worse off.
Ethical approaches that focus on maximizing net welfare—the ethics of the Hippocratic Oath and utilitarianism—hold that the only morally relevant feature of behavior is the outcome: the benefits and harms. By contrast, some ethical systems go beyond consequences to recognize other relevant features of actions. Fidelity and respect for autonomy are examples we encountered in the two previous chapters. Telling the truth might be another. The philosopher Immanuel Kant, for example, said that “[t]o be truthful (honest) in all declarations is . . . a sacred and unconditional command of reason, and not to be limited by any expediency.”1
Until about 1975, most health care professionals, at least most physicians, were Hippocratic. They believed it was ethically acceptable—indeed ethically required—to lie to patients when they thought it would benefit them.2 Since that time, attitudes have shifted dramatically. Now many health care professionals are questioning the ethics of lying to patients for their own good or for the good of others. The changes in attitudes have been so significant that there is currently a much greater inclination to disclose information to patients.3
In relatively few instances, dentists may feel that they are justified ethically in telling outright lies to patients or to others. More often the ethics of honesty raises questions of not completely disclosing the truth. The first cases in this chapter involve lies—statements made by dentists that they know are false. Some lies seem clearly indefensible. Others are more debatable because the dentist could offer some moral defense of the lie.
Luke Braddock was a 9-year-old child with a long history of dental experience. He had recently moved to a small midwestern community and in the process his family had delayed establishing a relationship with a new dentist. When Luke’s father brought him to Dr Hansen, Luke had serious problems, the worst of which was an unsalvageable permanent mandibular first molar that was causing serious pain. Although Dr Hansen did not like to contemplate extraction on a patient’s first visit, she determined that the extraction was necessary and needed to be done immediately to give the boy some relief.
Luke was moderately apprehensive about seeing a new dentist. He was trying to show courage. Finally, after the area was anesthetized, he asked Dr Hansen point-blank what she was going to do.
Dr Hansen had never been confronted so directly. She did not want to upset the child. After a short pause she said, “I’m just going to look in your mouth.” At that point she was already approaching carefully from behind Luke’s head so the boy could not see the forceps. The tooth was extracted before Luke knew what was happening.
There is no question that Dr Hansen meant well. She did not want to upset the boy by answering in a straightforward way that she was about to pull his tooth. On the spur of the moment, she could come up with nothing better than to tell what is sometimes called a “white” lie—that is, a lie that seems well intentioned.
If Dr Hansen were challenged to defend her lie, she probably would claim that she did what she believed was for the benefit of her patient. This, in fact, is exactly what the Hippocratic ethic would require. She was, no doubt, convinced that the boy would be terribly upset if told in advance about the extraction. Assuming that Dr Hansen really believed that the lie was the best thing for the boy in this awkward situation, an ethic of patient benefit would support the lie. The question is whether there are any reasons why it would bemorally wrong to say that she was just going to look when, in fact, she was going to extract.
In this case, it turned out that the patient was so upset with the surprise that he was horrified at the thought of returning to Dr Hansen and was never able to see her again. Even for a dentist motivated solely by doing what was best for the boy, the possibility of such psychological trauma should have been factored into the calculation of expected benefits and harms. Suppose that Dr Hansen carefully takes into account the risk of long-term trauma and still concludes that more good than harm is done by the lie. Is there then any reason why it would be wrong to tell this kind of lie? If you believe it would be wrong to lie, it could be for two different reasons: either because of the long-term bad consequences or because it is simply wrong for a dentist to lie, even for a good cause. Dr Hansen may not have adequately considered the long-term consequences of lying. In this case, she may not have realized that Luke would be so traumatized that a long-term fear of dentists could cause serious harm for many years. The other possibility is that it is simply immoral to tell a lie even if the consequences would be better than those of telling the truth. This is the position that Kant and many others have taken. Recently, the American Medical Association (AMA) has adopted this view as well. Lying to someone, according to those who hold this view, shows disrespect. It is wrong in the same way that breaking a promise or violating someone’s autonomy is wrong—regardless of the consequences. Those who hold this view may add the principle of veracity to their list of principles that make actions right. The principle of veracity is sometimes considered along with the principles of fidelity and autonomy as part of the general ethic of respect for persons. Others treat it as a separate principle. In either case, the fact that one is intentionally speaking dishonestly counts as a moral wrong even if doing so produces better consequences.
In Case 39, the patient was clearly the beneficiary, but no one (other than possibly the patient or the dentist) really would be harmed. Some argue that the health professional’s duty to do what will benefit the patient could even encompass lying for the patient when others (who are perhaps less deserving) would be harmed. The next case illustrates that situation.
Ms Mary Weiner, age 20, was a patient of Dr Sonya Hale, as were her brother and other family members. Mary had a history of seizures and had been taking Dilantin for a long time. Her seizures were controlled, but she had significant Dilantin hyperplasia. Dr Hale had planned to refer Mary to a periodontist to have the hyperplastic gingiva removed. However, the referral was delayed when Mary was in an automobile accident. She suffered facial fractures and significant trauma to other areas of her body. Multiple surgeries were necessary, and she was in the hospital for almost 8 weeks. In addition, at least one more surgery would be required.
When Mary next spoke to Dr Hale about the referral for gingival surgery, she asked if there was any way that Dr Hale could say that Mary’s facial trauma made the Dilantin hyperplasia worse so that the procedure could be covered under Mary’s general health insurance policy. If the hyperplasia had been caused simply by the Dilantin, her general health insurance would not cover the surgery, but if the trauma had been a contributing factor, the treatment would be covered. Mary obviously felt that she had been through so much that she deserved some kind of consideration from Dr Hale.
Dr Hale was troubled by the request. Although Mary was wearing arch bars because of the facial surgery, the resulting increased oral hygiene problems could have caused only a very minor increase in the already-existing hyperplasia. On the other hand, she sympathized with Mary and also did not want to lose the rest of the family as patients. Dr Hale thought about what she should do.
Two new issues are introduced in this case as compared with the previous one. First, there is a slight basis for saying that the accident caused at least some of the hyperplasia. Sometimes people distinguish between lying and merely withholding the full truth. The dentist could argue that because the accident could have caused some of the hyperplasia, she was dealing honestly with the insurance company, but that surely would be distorting the situation.
Even if Dr Hale concluded that the connection between the accident and the hyperplasia was tenuous at best, she might see the advantages to Mary in deceiving the insurance company as much more than the financial benefits alone. Deceiving the insurance company might also make it possible to combine the difficult hyperplasia surgery with the final facial surgery during a single general anesthetic. If that were done, Mary’s risks and discomfort would be considerably reduced. The question becomes one of whether the additional benefits for Mary would help Dr Hale justify stretching the truth in her dealings with the insurance company.
Second, the lie would cause injury to another party—the insurance company (and ultimately other subscribers to the insurance coverage). If the dentist is Hippocratic, she is devoted to doing what she believes will benefit the patient and protect the patient from harm. There seems to be no doubt that lying to the insurance company would benefit Mary. If the harm is done to other parties but not to Mary, there seems to be nothing wrong with the lie from the Hippocratic (patient-benefiting) perspective. However, there still may be other reasons why the lie or even the deception is ethically unacceptable. Two additional reasons to object to the lie can be considered: the harm done to others and the mere fact of telling a lie. A social utilitarian would consider the benefits and harms to other parties in addition to the patient. The harm to the insurance company and to fellow subscribers would then be included as a reason not to lie. The problem with social utilitarianism, however, is that it would require Dr Hale to compromise the patient’s interests whenever society would be better off, something most dentists would find unethical. That would leave the principle of honesty—that it is simply wrong to tell a lie or distort the truth as the basis for opposing Mary’s request. Defenders of the principle would conclude that it is unacceptable for Dr Hale to deceive the insurance company simply because it is dishonest, even if Mary would be better off.
Both of the previous cases present lies for the benefit of the patient, but one also might sometimes consider lying for the benefit of other parties. Lies in the interests of obtaining accurate information, as in the next case, can be told in order to obtain important information from respondents who otherwise might not answer questions honestly.
From his earliest days, Dr Dan Barney was the sort of person who believed in treating people fairly. It was the way that everyone in his family felt about life—and they were vocal about it. Everyone knew where the Barneys stood on public matters: It was always on the side of the underdog.
When Dr Barney graduated from dental school, he became a pediatric dentist and opened a practice in his hometown. When Medicaid patients called for appointments, he accepted them. He knew that other dentists in town refused to treat them, but his view was, “They’re kids! How can you turn a kid down? That’s what I’m there for!” Soon his practice was 30 percent Medicaid, and after 10 years, it was half Medicaid. Dr Barney was largely oblivious to these trends in his practice, but his office manager pointed out that he could make a lot more money if he cut back on his Medicaid patients.
Dr Barney wouldn’t do it. He thought his income was not too bad as it was. Furthermore, these were the kids who needed care the most. However, his office manager’s concerns about Medicaid made him aware of two very different issues. One was just how bad the Medicaid fees were. As a result, Dr Barney initiated a decade-long campaign to raise the Medicaid fees in his state, which had some of the lowest fees in the country. He worked tirelessly to provide his state with documentation that low-income children were being denied access to dental care. Because of that documentation and his persistence in acquiring the support of elected state officials, including the attorney general and finally the governor, his campaign prevailed and the fees were raised.
The second by-product of Dr Barney’s newly acquired awareness about Medicaid was his realization that very few dentists were caring for these patients. He would see children who traveled 60 miles to get to his office and in so doing, passed by the offices of 20 or 30 dentists who would not accept Medicaid patients. This realization gnawed at him, and the more he thought about it, the angrier he became. That anger influenced the way that he acquired data for his campaign to raise Medicaid fees. Between patents, he began personally calling the offices of a large sample of the dentists in the state, including both pediatric and general dentists. He would tell the receptionist who answered that he was the father of a young child with dental pain and swelling and would ask for an appointment. The office staff would begin the appointment process, but when they discovered the child was on Medicaid, the door was usually shut. The results of Dr Barney’s survey were quite discouraging.
At a meeting of the state’s pediatric dentists, Dr Barney disclosed what he had been doing. Although some of his colleagues congratulated him, many others were disturbed by his actions.