What do people really think of dishonest medical professionals? Does integrity really matter?
In fitness to practise cases, the need to uphold public confidence in the profession is often cited as a factor justifying strict sanctions like suspension or erasure. Until recently however, the type of conduct that might affect the public perception in real terms was unknown, as there was no hard evidence of how the public actually perceived dishonest actions by the medical profession.
The Professional Standards Authority (PSA) oversees and scrutinises the UK health and social care regulators, such as the GMC. It reviews all final decisions by the regulators' fitness to practise committees and has the power to appeal the decision to the court if it believes the sanction is too lenient. In recent years, the number of dishonesty cases appealed by the PSA has increased. To gain some insight, in 2016 the PSA commissioned research to better understand the public perception of dishonest conduct by health professionals. The public were asked to consider nine dishonest scenarios from real cases. The conduct ranged from falsifying records, to lying about insurance, to theft. Participants had to decide which penalty was appropriate in each case.
The findings are of interest from a defence perspective. Many participants took a pragmatic and tolerant view in all but the most deplorable cases. They emphasised a preference towards changing behaviour and rehabilitation as well as allowing the professional to retain their registration.
Twelve common factors were found to aggravate dishonesty and listed in order of gravity. Unsurprisingly, predatory behaviour was seen as the most grievous. Misuse of power and abuse of vulnerable individuals was shown little tolerance, as was behaviour motivated by personal gain. Sexual exploitation of patients was also particularly unforgiveable. On the other hand, lack of insight or remorse was considered strikingly insignificant at tenth place on the list. This is at odds with the pivotal role that insight typically plays in fitness to practise cases, in which the defence often focus large sections of evidence on demonstrating that the doctor has learned their lesson. It also contrasts with the growing emphasis in medical practice on accepting responsibility and apologising when things go wrong.
Research participants also examined mitigating factors. Curiously, integrity was seen as more important in some professions than others. In practical professions like dentistry, there was seen to be less need for absolute integrity than in those involving decision making or vulnerable people, such as social work. A prime example is the case of a dentist who committed tax fraud on rental income from his property portfolio. This type of dishonest conduct, although criminal, was considered irrelevant to his fitness to practise. This is a point that is often made by the defence but effectively dismissed by fitness to practise committees.
The PSA research is a double-edged sword for professionals facing fitness to practise proceedings for dishonesty. There are some helpful points to be deployed, but there are also many less than helpful findings. For instance, all participants agreed that premeditated, systemic or longstanding abuse of trust is grounds for swift erasure. The same view was taken of dishonesty for financial gain, and of sexual exploitation. Broadly speaking, the participants were also supportive of the PSA's decisions in the cases where it had appealed over-lenient sanctions.
In some respects, this research perhaps highlights the obvious. In the right case however, it could prove a persuasive tool to steer the panel away from suspension or erasure. Used properly, it should also mean more decisions are based on a genuine understanding of how dishonest conduct affects the public confidence, rather than the individual panel member's perception of what matters. In theory that should be a good thing – in practice, it remains to be seen.