Jos VM Welie
Center for Health Policy and Ethics, Creighton University, Omaha, USA

The Limits of Truthfulness
Ethical reflections on the provision of information in the dental care context

Information as a consumer good

The profession of dentistry, ever since its emergence in the mid 19th century, has been concerned with the provision of information and, more specifically, the veracity (or truthfulness) of such information. The advent of mass media has rendered the old shingles, billboards, and business cards virtually obsolete. Instead, dentists and dental product manufacturers now resort to high gloss multi-color newspaper inserts, sophisticated radio messages, professional television advertisements, direct mailings, and interactive internet sites.
Patients are provided with more information about their oral health than ever before in history, much of which is not intended to promote the health interests of the patients but rather the business interests of the providers. And those providers, whether they be individual dentists or dental product manufacturers, know about and eagerly make use of the power of information, its ability to evoke desires and fears, to change viewpoints, to direct behavior. In turn, ethical watchdogs strive to protect patients by insisting on truth standards. The American Dental Association when it reformatted its Code of Ethics several years ago, naming each section after one of the classic principles of bioethics, even decided to add to the existing four principles (beneficence, nonmaleficence, autonomy, and justice) a fifth one, the principle of veracity.
Unquestionably, it is of paramount importance to protect consumers against false or misleading information by insisting on the veracity of all service and product information. But we have to remember that the consumers of oral health care services and products often are patients rather than mere consumers. Additionally, in the context of oral health care, information is never mere information. Although truthfulness is always important, the specific function of the informative act within the therapeutical relationship entails additional criteria by which to judge the information provided. I distinguish four specific functions.
 

Information as condition of informed consent

Since it is the patient who is suffering from the oral disease, who shall undergo the treatment, who will benefit from the intervention as well as suffer the side-effects and any accidental harm caused, and who must pay for the procedures, the patient has a right to consent prior to treatment. In and of itself, this right is not much different from the guest’s right to explicitly order food prior to being served by the waiter; a waiter is not supposed to simply bring out foods that the client did not request. However, the patient’s right of consent is a qualified right, for it is the right to an “informed consent.” A patient’s consent to treatment is invalid if the patient was not provided by the health care professional with any and all information that the patient needs (or may need) to make a sound decision about his/her health care. This is not true of the guest in the restaurant. If the guest asks questions, she should be answered honestly. But the waiter does not have to volunteer information. He certainly does not have to warn his guest against certain dishes on the menu that aren’t very good; he does not have to counsel her that if she wishes to eat a really excellent steak, she should go to restaurant around the corner. But patients must be provided with such information because the relationship between health care professional and patient is fundamentally different from that between service providers who operate on the free market and their consuming clients.
These examples show that truthfulness is a necessary condition for a valid informed consent, but not a sufficient condition. The information should be relevant to the patient, yield a greater understanding of his condition and therapeutical options, and thus allow for a choice that is most likely to be commensurate with the patient’s authentic values and his best interests. Information that is neither false nor misleads the assertive consumer – the ultimate test for dental advertisements – may well be misleading for the purposes of a true informed consent.
 

Information as fundamental human right.

Even if there is no diagnosis or therapy to be consented to, patients still have the right to be informed by their health care providers about their own medical condition, their diagnosis and prognosis. After all, the information that health care professionals collect about a patient is the patient’s information. The record paper (or electronic software) may be owned by the dentist, but not the information itself. In this regard the health care provider differs fundamentally from the scientist who, by virtue of the labor invested, can lay claim to the information he or she discovers (e.g., copyright and patent right). The fact that the dentist labors to correctly diagnose a patient’s oral condition yields him or her the right to payments from the patient, but not to the information itself. The dentist is therefore obligated to continuously and completely update the patient about new information gathered about the patient’s own condition and to promptly make available copies of the patient’s own record if so asked by the patient.
In this context, truthfulness is necessary. But the naked truth once again does not suffice. Lying to or misleading consumers of oral health services and products is a serious violation of the “rules of the game” of free market trading. But lying to or misleading patients about their medical condition is a violation of the trust patients have vested in their care givers. The patient allows the dentist access to his body and his life-style, to take pictures and laboratory tests. The information thus collected is not really the dentist’s. For a dentist to intentionally falsify or withhold such information from the patient violates the patient’s very human dignity. But so would be a failure on the dentist’s part to explain the information in terms that the patient really understands.
 

Information as compliance booster.

On of the key concerns in all of health care, and particularly in oral health care, is patient (non)compliance. If patients fail to comply with cleaning instructions, medications or orthodontic maintenance, much of what a dentist or hygienist does during the office visit will soon be undone. Patient compliance can be attained only trough persuasion. In the absence of such forceful persuaders as pain or discomfort, understanding becomes the primary means of motivating patients to comply. In turn, understanding is achieved foremost through information.
The patient’s role in the therapeutical plan is not limited to complying with the therapists’ instructions, whether in the chair or back home. Oral health to a large degree is effectuated not by the dentist or hygienist, but by the patients themselves. Patients either use or abstain from harmful products such as sweets, tobacco, or illegal drugs; it is up to them to buy fluoridated water; they must purchase dental insurance or set aside the funds to pay out of pocket. In short, patients share in the burden of caring for their dentition and in order for them to do so effectively, they must be instructed.
In this context, the temptation to employ “white lies” is significant. We may be tempted to instil fear in the patient by exaggerating the possible dangers of non-compliance or by threatening to dismiss the patient from our practice. Alternatively, we may want to strongly emphasize all the benefits of compliance, hoping the patient will be sufficiently motivated to bear the burdens. Though potentially effective in the short run, such violations of the principle of veracity in the long run may severely undermine the patient’s trust in the care giver and thus hamper an effective lasting therapeutical relationship. But again, the “whole truth and nothing but the truth” generally does not suffice to achieve good compliance from patients. Truthful communications with patients will only boost compliance if they also reflect empathy, concern, trustworthiness, objectivity, authority, understanding and fairness.
 

Information as therapy

In the compliance examples listed above, information is only a means towards achieving some form of therapy. However, information has itself therapeutical value as well. The healing power of information is most evident in the field of psychotherapy. But we now also know that almost all drugs derive their curative power at least in part from the so-called “placebo” effect, which is itself in large part due to the information provided by the care giver.  More in general, information heals. It can calm an anxious patient, relieve tension, lessen fears, instil persistence, boost courage, create hope. By the same token, information can also harm. It can confuse patients, upset them, render them more fearful, angry or stressed.

The art of healing through words is probably the most sophisticated of medical arts. Truthfulness in this context is at most a side-constraint. As the “placebo” effect underscores, the healing power of communications between care giver and patient is seldom a function of the truthfulness of the information provided. The therapist participates in the rewriting of the patient’s story, or rather, of the story which is the patient (to borrow jargon from deconstructivist philosophers). Story telling is very different from truth telling. They are simply not in the same category to even allow a comparison.
 

Conclusion

The forgoing reflections on the multiple and multifaceted ways in which information figures in the therapeutical relationship between dentist and patient are not intended to deny the importance of truthfulness. Rather, they are intended to remind us that the criterion of truthfulness, while it may suffice to evaluate commercial communications between providers of dental services and products, is only a necessary but never a sufficient condition in the context of clinical patient care. Thus, clinical care givers, and all of us who are concerned about the ethical quality of clinical dental care, may not be satisfied with ethics policies or codes that emphasize veracity and only veracity. Words are too powerful to be captured by the principle of veracity.

Contact Address: