Advances in Medical Ethics
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The Ethics of Dishonesty in Medicine: “Assuming Risk” and Navigating the Road to Redemption

Mohammad Salhab^{* *}Correspondence: Mohammad Salhab, Department of Orthopedics, Centre of Bone Disease and Surgery, Beirut, Lebanon, Email:

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Introduction

Honesty is a fundamental principle in the practice of medicine, forming the bedrock of trust upon which the doctor-patient relationship is built [1]. When a healthcare provider engages in dishonest behaviour, the consequences can be far-reaching, damaging not only to patients but also the integrity of the profession as a whole [2]. This article explores the ethical dimensions of dishonesty in medicine, drawing on philosophical arguments to understand the gravity of these transgressions and the potential for redemption.

The philosophical underpinnings of medical ethics

The ethics of medicine are grounded in a rich philosophical tradition, with principles such as autonomy, beneficence, nonmaleficence, and justice forming the core of professional obligations [3]. Dishonesty, in this context, represents a fundamental breach of these principles, violating the deontological duty of veracity, the consequentialist aim of maximising good outcomes, and the virtue-based ideal of moral character [4].

From a deontological perspective, healthcare providers have an intrinsic duty to be truthful with their patients, providing accurate information and obtaining informed consent [5,6]. Dishonesty, whether through falsifying records, misrepresenting qualifications, or withholding information, is inherently wrong, regardless of the consequences [7]. The issues arise when the actions span the realms of the doctor’s work boundaries and reflect on one’s personal issues. Such personal liability of dishonest action in one’s personal life can have implications on the moral grounds and integrity of the profession as a whole and the question of whether there is a distinction between dishonesty and deception [8-10].

The ethical implications of dishonesty in a doctor's personal life

When one considers the impact of a doctor's dishonest actions, it's essential to examine not only their professional conduct but also their personal life. While some may argue that what happens outside of the clinical setting is separate from a doctor's work, there are compelling ethical reasons to consider the broader implications of dishonesty, regardless of where it occurs [10]. There are strong ethical arguments for considering the wider ramifications of dishonesty, irrespective of the context in which it takes place.

Several moral factors can influence a doctor's behaviour, even if the dishonest actions occurred within their personal life. These include integrity and trust, spillover effects, public trust, professional responsibilities, and moral goodness. While a doctor's personal life may seem separate from their professional duties, the ethical implications of dishonesty in any context cannot be disregarded. Doctors are held to the highest standards of integrity and moral character, as their trustworthiness is essential to the effective and ethical practice of medicine.

The nature of dishonest actions

Dishonest actions in a doctor's personal life can take many forms like “white lies” to more serious breaches like infidelity, financial fraud, or substance abuse. While the severity of these actions may vary, they all share a common thread: the willingness to deceive or mislead others for personal gain or to avoid negative consequences. In this respect however, this comes across as a judgemental assumption and a better approach would be an “assumption of risk”.

Dishonesty encompasses a wide range of behaviours, with some of the most common being cheating, lying, fabrication, sabotage, and impersonation [11]. However, the concept of dishonesty extends beyond these overt acts and includes more subtle forms of deception. Deception can involve omitting relevant information, misreporting facts, or conveying misleading messages, among other similar behaviours. While these actions may not always be classified as outright lies, they still fall under the umbrella of dishonest conduct, as they involve an intentional departure from the truth or an attempt to mislead others.

The question of whether an individual who has been found to be dishonest will always continue to engage in dishonest behaviour is a complex one. While it is difficult to make definitive predictions about future behaviour, research is lacking in this area. Cognition and dishonest behaviour are firmly related but the intriguing dynamic of this correlation is further form being understood [11].

Deceit and dishonesty can be seen as reactions to the use of personal or institutional authority within the framework of a social practice. These reactions are influenced by both the individual's own inclinations and biases, as well as the norms and values of the society in which they operate. Deceit and honesty can also be attributed to the complexities of power share and also who is in position of trust. The interplay between deceit and honesty can also be understood in the context of the intricacies of power dynamics and the role of those who hold positions of trust. The distribution of power within relationships and institutions can significantly influence the prevalence and nature of truthfulness or dishonesty in these settings [12].

The emotional state of an individual can significantly influence their propensity for honesty. Research has shown that people who are in a positive emotional state, such as happiness, are more likely to exhibit honest behaviour compared to those in a neutral emotional condition. This suggests that a person's emotional well-being plays a pivotal role in determining their inclination towards truthfulness.

It is evident that even individuals with a history of excellent performance may resort to dishonesty when they are struggling to cope with personal challenges or recovering from health issues. The conflict between personal life and professional responsibilities seems to be a significant yet often overlooked factor contributing to such behaviour. Research indicates that acute stress can have a significant impact on an individual's moral decision-making processes. When faced with high-pressure situations or intense stress, people may be more likely to make choices that deviate from their typical moral standards. Interestingly, when stress triggers emotions that are primarily self-oriented, such as fear or anxiety about personal well-being or self-preservation, it may increase the likelihood of engaging in selfish deception.

It seems that honest individuals engage in dishonest behaviour just enough to benefit from it, while still preserving their selfperception of integrity. In other words, it seems that honest people may engage in dishonesty to the extent that it yields personal gain, but not to the point where it significantly tarnishes their perception of themselves as morally upright. For example, it appears that centres in areas with multiple competitors manipulated the waiting list to ensure that the sickest patients received a liver transplant. In such circumstances the transplant surgeons’ financial and prosocial motivations may have led to dishonest patient reporting despite the intention to serve the sickest patients.

Studies have shown that dishonesty can be influenced by factors such as self-control, moral disengagement, and the perceived costs and benefits of the behaviour. However, it is important to note that not all individuals who engage in dishonest behaviour will continue to do so in the future. Research has identified several factors that can influence the likelihood of repeated dishonesty, such as the individual's moral identity, the strength of their moral convictions, and their capacity for self. Additionally, situational factors such as the presence of ethical codes, monitoring systems, and social norms can also play a role in deterring future dishonesty.

The risk of repeated dishonesty may also depend on the consequences faced by the individual following their initial dishonest act. Studies have suggested that the experience of guilt, shame, and other negative emotions following a transgression can serve as a deterrent to future unethical behaviour. Similarly, facing disciplinary action or other punitive measures may also reduce the likelihood of repeated dishonesty, particularly if the consequences are perceived as fair and proportionate to the offence. Many individuals, at some point in their lives, will engage in dishonest acts such as lying or prioritising their own interests at the cost of others. These unethical behaviours vary in severity, and in some cases, it may be ambiguous whether certain actions should be considered unethical at all. However, even seemingly minor transgressions can become cause for concern if they are repeated and gradually escalate into more serious forms of unethical conduct. The repetition and intensification of these "little sins" can lead to a slippery slope, where the individual becomes increasingly comfortable with engaging in dishonest practices, potentially leading to more significant ethical breaches over time. Even people with high moral standards can engage in unethical behaviours.

The importance of integrity

At the heart of the medical profession is the principle of integrity-the quality of being honest, morally upright, and consistent in one's actions and values. Integrity is essential for building and maintaining trust, both with individual patients and with society as a whole. Integrity is portrayed as a complex social virtue that enables individuals to demonstrate their alignment with the values and mores of the communities they belong to, including their profession. This implies that integrity is not just a personal value but also a way for healthcare professionals to show their commitment to the shared values of their field. When a doctor engages in dishonest behaviour, even in their personal life, it calls into question their integrity and their commitment to ethical principles.

Integrity is also crucial from a consequentialist standpoint, as it directly impacts the outcomes of medical care. Consequentialist theories judge the morality of an action based on its results, and dishonesty in medicine can lead to a range of negative consequences, such as misdiagnosis, inappropriate treatment, and harm to patients. By upholding integrity, healthcare professionals can ensure better outcomes and minimise the potential for harm.

Moreover, integrity is a key component of virtue ethics, which focuses on the moral character of the individual. Virtue ethics emphasises the importance of cultivating virtues such as honesty, compassion, and trustworthiness, and integrity encompasses all of these qualities. By embodying integrity, healthcare professionals demonstrate their commitment to these virtues and serve as moral exemplars for others in the profession.

Integrity is thus a complex and multifaceted concept that is deeply rooted in all three major philosophical approaches to ethics. It is not just a personal value but also a professional obligation, a means of ensuring good consequences, and a reflection of moral character. When a doctor engages in dishonest behaviour, even in their personal life, it calls into question their integrity on all of these levels and undermines the trust that is so essential to the practice of medicine.

It is important to note that the concept of dishonesty and its application to the conduct of professionals has undergone a significant shift due to the infamous supreme court case in 2018, Ivey v genting casinos. This ruling has clarified the test for determining dishonesty, which was previously thought to be wellestablished. The test now consists of two parts.

•The tribunal or panel must first ascertain the individual's actual knowledge or belief regarding the facts.
•The tribunal or panel must then determine whether the individual's conduct was honest or dishonest by applying the (objective) standards of ordinary decent people.

Literature Review

There appears to be a potential overlap between dishonesty and lack of integrity. In some cases, it may be possible for an individual to exhibit both characteristics, either separately or in relation to the same matter. The question arises, considering the severity of dishonesty, whether recognising a lack of integrity separately could facilitate a better understanding of the error of one’s behaviour. Alternatively, perhaps it would be more fitting to consider dishonesty and lack of integrity as part of a single spectrum of behaviours, with varying degrees of distinction between the two.

Regulators of the health professions tend to uphold "proper standards" and maintain public trust when faced with an incidents of dishonesty. However, if a practitioner demonstrates a lack of understanding regarding the implications of their actions, a temporary suspension from practice may be imposed. During this suspension period, the practitioner is required to engage in self-reflection and introspection. In cases where there is a persistent risk to patient safety, or when a practitioner fails to develop clear insight and actively participate in the remediation process, a striking-off order may be deemed necessary to protect the public and preserve the integrity of the profession.

The spillover effect

Dishonesty in personal life can have a spillover effect on professional conduct. If a doctor is willing to deceive or mislead in their private life, it raises concerns about their ability to maintain honesty and integrity in their clinical practice. This is particularly concerning given the power imbalance between doctors and patients and the vulnerability of those seeking medical care.

Some may argue that personal and professional conduct should be considered separately and that what a doctor does in their private life has no bearing on their ability to provide quality care. According to this view, as long as a doctor maintains high standards of honesty and integrity in their clinical practice, their personal behaviour is irrelevant.

However, this argument fails to recognise the fundamental importance of trust in the doctor-patient relationship. Patients place a great deal of trust in their doctors and health professionals, not only to provide competent medical care but also to be honest and forthright in all of their dealings. When a doctor's personal integrity is called into question, it can erode this trust and undermine the therapeutic alliance.

Moreover, the spillover effect is not just a matter of public perception but also of psychological reality. Habits of dishonesty and deception, once established, can be difficult to confine to one area of life. A health professional who becomes comfortable with dishonesty in their personal affairs may be more likely to let those habits creep into their professional conduct, whether consciously or unconsciously.

It is also worth noting that the personal lives of doctors are not entirely private. In today's interconnected world, information about a doctor's personal conduct can quickly become public knowledge, particularly if it involves illegal or unethical behaviour. In such cases, the spillover effect can be immediate and devastating, leading to a loss of public trust and potentially severe professional consequences.

While it is important to respect the privacy and autonomy of doctors and health professionals in their personal lives, it is equally important to recognise that personal and professional integrity are deeply intertwined. Doctors have a heightened responsibility to maintain honesty and ethical conduct in all aspects of their lives, given the trust placed in them by patients and society as a whole.

The public trust

Doctors occupy a unique position of trust in society, with the authority to make decisions that profoundly impact the lives and well-being of others. This trust is not confined to the clinic or hospital but extends to the public's overall perception of the medical profession. When a doctor's personal dishonesty comes to light, it can erode public confidence in the profession as a whole, undermining the essential bond between medicine and society.

The role model effect

Doctors are often seen as role models, both within the medical community and in the broader public sphere. Their actions and behaviours, both professional and personal, can influence the attitudes and choices of others, particularly aspiring medical professionals. If a doctor's personal life is marked by dishonesty, it sends a troubling message about the values and standards of the profession.

The duty to self-regulate

The medical profession has a duty to self-regulate, ensuring that its members adhere to the highest ethical standards. This duty extends beyond clinical competence to encompass personal integrity and moral character. When a doctor's personal dishonesty comes to light, it is incumbent upon the profession to assess the implications for their fitness to practice and to take appropriate action, such as mandating rehabilitation or, in severe cases, revoking licensure.

Consequentialist theories, such as utilitarianism, judge the morality of an action by its outcomes. Dishonesty in medicine can lead to misdiagnosis, inappropriate treatment, and harm to patients, undermining trust in the profession and contributing to systemic problems like rising healthcare costs and resource misallocation.

Virtue ethics emphasises the importance of moral character, with honesty, integrity, and compassion as essential virtues for healthcare providers. Dishonesty, in this view, represents a failure of character and a departure from the moral standards that should guide medical practice.

The gray areas of dishonesty

To effectively address dishonesty in the medical profession, it is essential to understand the underlying causes and motivations behind the behaviour. Establishing causality can provide valuable insight into the individual's actions and help determine the most appropriate course of action. For instance, if a doctor's dishonesty stems from a lack of understanding or a momentary lapse in judgment, a rehabilitative approach focused on education and reflection may be more suitable than punitive measures.

As discussed previously, dishonesty can be aggravated by various factors, such as the frequency of the behaviour, the level of premeditation involved, and the potential harm caused to others. Moreover, dishonesty can have a spillover effect, whereby one lie or dishonest act leads to a cascade of subsequent lies to maintain the deception.

When a medical professional confesses to dishonesty, it is important to consider whether this admission demonstrates sufficient insight into the gravity of their actions. While confession is a crucial first step, true insight requires a deeper understanding of the consequences of one's behaviour and a genuine commitment to rectifying the situation. A lack of insight, even in the face of confession, may warrant more significant intervention to ensure that the individual comprehends the severity of their misconduct and takes appropriate steps to prevent future occurrences. The question is do regulators have enough interim measures to address such cases instead of resorting to extreme measures such as suspension or erasure.

The lack of clear guidelines and case law surrounding dishonesty in the medical profession can lead to inconsistencies in how cases are handled. While a case-by-case approach allows for flexibility and consideration of individual circumstances, it may also result in a form of injustice if similar cases are treated differently. To strike a balance between justice and consistency, it is necessary to establish a framework that takes into account the severity of the dishonest act, the potential impact on patient care and public trust, and the individual's level of insight and remorse.

When considering the significance of dishonest actions, it is essential to prioritise the protection of the public. The public may be more concerned about a doctor who falsifies their qualifications or engages in dishonest practices that directly impact patient care than a doctor who is dishonest in their personal financial dealings. However, both cases should be taken seriously, as dishonesty in any form can undermine public trust in the medical profession. The severity of the response should be proportionate to the potential harm caused and the individual's willingness to take responsibility and rectify such behaviour.

Discussion

The consequences of dishonesty and the path to redemption

For doctors who have engaged in dishonest behavior, the consequences can be severe, including legal penalties, professional sanctions, and a devastating loss of public trust. The road to redemption is a challenging one, requiring not only personal and professional rehabilitation but also the difficult work of rebuilding trust and confidence among patients and the broader healthcare community.

The journey of redemption begins with taking responsibility for one's actions, expressing genuine remorse, and engaging in a process of atonement and rehabilitation. This may involve public apologies, community service, and a commitment to ongoing education and ethical growth. It also requires transparency about the steps being taken to address past misconduct and a willingness to be held accountable by professional organisations and regulatory bodies.

This section offers measurable steps that when faced with such actions, health professionals should be seeking legal advice and guidance from professionals such as expert psychologists and life coaches. These professionals may play an important role in developing insight and understanding the root causes underlying such dishonest behaviour. The first step on the path to redemption is gaining insight into the factors that contributed to the dishonest behavior. This requires honest self-reflection and a willingness to confront uncomfortable truths about oneself. The health professional must ask difficult questions: What underlying issues, such as stress, addiction, or unresolved trauma, may have influenced their actions? What cognitive distortions or ethical blind spots allowed them to justify their behavior? By gaining a deep understanding of the root causes of their dishonesty, the doctor can begin to address these issues and develop strategies for preventing future transgressions.

Remediation is another critical step in showing genuine remorse regarding one’s actions and attempting to take responsibility for one’s actions and also demonstrate insight. Insight alone is therefore not enough; it must be accompanied by concrete actions to remediate the harm caused and demonstrate a commitment to change. Depending on the nature of the dishonest behavior, this may involve seeking treatment for substance abuse or mental health issues, making amends to those who were harmed, and engaging in community service or other forms of restitution. It may also require disclosing the misconduct to relevant authorities and accepting the consequences, such as disciplinary action or temporary restrictions on medical practice. Crucially, remediation efforts should be guided by a comprehensive plan developed in consultation with mentors, therapists, and other support systems. This plan should include specific goals, timelines, and benchmarks for progress, as well as mechanisms for accountability and ongoing support.

Cultivating and developing a moral character should therefore primarily demonstrate insight and remediation and what other steps will there be in place to minimise the risk and prevent dishonest actions from repeating or creating a spillover. Redemption is not just about addressing past misdeeds but also about cultivating the moral character necessary for future ethical practice. This involves a commitment to ongoing learning and growth, both in terms of clinical competence and ethical reasoning.

The doctor or health professional should actively engage with the principles and values of medical ethics, studying relevant literature and case studies, and participating in discussions and workshops with colleagues. They should seek out mentorship from experienced practitioners known for their integrity and moral leadership, learning from their example and guidance.

Ethical development also requires regular self-assessment and reflection. The health professional should establish habits of examining their own actions and decisions through the lens of ethical principles, seeking feedback from trusted peers, and being open to constructive criticism. By continuously honing their ethical skills and deepening their commitment to integrity, the doctor can work towards embodying the ideals of the medical profession. Therefore, probity courses and case law examinations and regulators guidance offer continuous professional development in this field.

As the doctor progresses on the road to redemption, it is essential to work towards rebuilding trust with patients, colleagues, and the broader community. This requires a proactive approach to transparency and accountability. The doctor should be open and honest about their past misconduct, the steps they have taken to address it, and their ongoing efforts to maintain ethical standards. Such progressive action should be documented, evidenced and reflected upon. This can be achieved using a personal blog or this may involve sharing their story with colleagues, participating in public education initiatives, or advocating for policies and practices that promote integrity in healthcare.

Accountability also means being willing to accept ongoing oversight and monitoring, such as regular check-ins with a professional mentor or ethics committee. By demonstrating a consistent commitment to ethical behavior over time, the health professional can gradually rebuild the trust that was lost and reestablish their standing within the medical community.

While the burden of redemption falls primarily on the individual doctor, it is important to recognise the role of forgiveness and support from others. Colleagues, loved ones, and even patients who have been harmed can play a crucial role in the doctor's journey by offering understanding, encouragement, and opportunities for growth.

This does not mean excusing or minimising the harm caused by the dishonest behaviour, but rather recognising the human capacity for change and the potential for even the most serious ethical breaches to become opportunities for learning and transformation.

The medical profession as a whole also has a responsibility to support colleagues who are striving to redeem themselves, providing resources, guidance, and a path back to ethical practice. By fostering a culture of compassion and accountability, the profession can help its members navigate the difficult road to redemption and emerge stronger, wiser, and more committed to the highest ideals of medicine.

Conclusion

The road to redemption for doctors who have been dishonest in their personal lives is a challenging but an essential journey. By gaining insight into the root causes of their behaviour, taking concrete steps to remediate harm, and committing to ongoing ethical development, these individuals can work to rebuild trust and reestablish their integrity. There should not be a time imposed on such journey but rather support along the journey with adequate professional guidance, education and consolidation of actions taken by the person involved.

Ultimately, the path to redemption is about more than just individual rehabilitation; it is about upholding the fundamental values of the medical profession and ensuring that patients can continue to place their trust in the hands of those who care for them. By supporting and guiding colleagues on this journey, the medical community can demonstrate its commitment to these values and its willingness to confront even the most difficult ethical challenges with compassion, wisdom, and unwavering dedication to the greater good.

Crucially, redemption should not a solitary endeavour. It requires the support of colleagues, professionals and as well as the broader society. Forgiveness, in this context, is not about excusing past wrongs but about recognising the capacity for change and creating the conditions that allow for ethical rehabilitation.

Ethical Approval

Not applicable.

Consent for Publication

Author consents to publishing material relating to this work.

Availability of Data and Materials

We do not analyse or generate any datasets, because our work proceeds within a theoretical and mathematical approach.

Competing Interests

Non declared.

Funding

Non declared.

Authors' Contributions

Mohammad Salhab (MS) has made all contributions to the conception, the acquisition, analysis, interpretation of data; and work and substantively revised it. MS has approved the submitted version (and any substantially modified version that involves the author's contribution to the study) and has agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Acknowledgements

I would like to thank kaines Innes for his support and kind words.

References

1. Zolkefli Y. The ethics of truth-telling in health-care settings. Malays J Med Sci. 2018;25(3):135.

   [Crossref] [Google Scholar] [PubMed]

2. Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17-28.

   [Crossref] [Google Scholar] [PubMed]

3. Griffin AS, Callen A, Klop-Toker K, Scanlon RJ, Hayward MW. Compassionate conservation clashes with conservation biology: Should empathy, compassion, and deontological moral principles drive conservation practice? Front Psychol. 2020;11:1139.

   [Crossref] [Google Scholar] [PubMed]

4. Tseng PE, Wang YH. Deontological or utilitarian? An eternal ethical dilemma in outbreak. Int J Environ Res Public Health. 2021;18(16):8565.

   [Crossref] [Google Scholar] [PubMed]

5. Benlahcene A, Zainuddin RB, Syakiran N, Ismail AB. A narrative review of ethics theories: Teleological and deontological Ethics. J Human Soc Sci. 2018;23(1):31-32.

   [Google Scholar]

6. Edwin AK. Don't lie but don't tell the whole truth: The therapeutic privilege-is it ever justified? Ghana Med J. 2008;42(4):156.

   [Google Scholar] [PubMed]

7. Bakhurst D. On lying and deceiving. J Med Ethics. 1992;18(2):63-66.

   [Crossref] [Google Scholar] [PubMed]

8. Evans D. An ethical dilemma: The dishonest doctor. Nurs Forum. 1995;30(3):5-11.

   [Crossref] [Google Scholar] [PubMed]

9. Blasszauer B. Bioethics and corruption: A personal struggle. Indian J Med Ethics. 2013;10(3):171-175.

   [Crossref] [Google Scholar] [PubMed]

10. Munoz GA, Gil-Gomez de Liano B, Pascual-Ezama D. The Role of Cognition in Dishonest Behavior. Brain Sci. 2023;13(3):394.

    [Crossref] [Google Scholar] [PubMed]

11. Carter M. Deceit and dishonesty as practice: The comfort of lying. Nurs Philos. 2016;17(3):202-210.

    [Crossref] [Google Scholar] [PubMed]

12. Medai E, Noussair CN. Positive emotion and honesty. Front Psychol. 2021;12:694-841.

    [Crossref] [Google Scholar] [PubMed]