Dental Ethics – Dentistry, like medicine, is a Hippocratic profession. It has developed and now uses a set of techniques that have evolved rapidly and discernibly within the few decades. Hippocrates incorporated into his school of thoughts three ingredients which have survived into contemporary health care practice:
First, there was a skill or art which was learned by apprenticeship in dealing with actual cases with proper dental ethics.
Second, there was a search for the natural explanations of disease and an attempt to build up a body of scientific knowledge which could be used to inform one’s skill.
Third, there was an ethos of caring and respect for human beings which is now called as dental ethics.
The first two elements made the Hippocratic approach to medicine a suitable foundation of dental ethics for a tradition of health care apt to continue into a scientific age. The third element of the Hippocratic approach is the one most often remembered because it has survived in the Hippocratic Oath. It guards medical practice against the unscrupulous use of that specialized and privileged knowledge which has been obtained in an attempt to offer real benefits to suffering people. The Hippocratic school was so concerned that the art they practiced should be surrounded by the dental ethics which they considered important that their oath included the words:
I will impart knowledge of the Art to my, own sons and those of my teachers and to the disciples bound by a stipulation and oath according to the law of medicine but to no other. (Gfflett, 1989).
The implication of this underlying dental ethics commitment is that any Hippocratic professional must primarily share a caring ethos and that only on that basis was he fit to learn the specialized skills of clinical care. The Hippocratic stress on caring and benefit is often misinterpreted as expressing a relative neglect, in health care practice, of the respect for the patient as a person.
The value commitments of the Hippocratic tradition can, however, create conflicts in practice-for instance, between the desire for standardized and comprehensive knowledge and the need to respect persons as individuals. Despite these conflicts, such dental ethics commitments remain an inescapable part of the proper function of a health care profession. Therefore, we must find dental ethics resolutions to the various conflicts that can arise if we are to practice properly as Hippocratic professionals.
The dental profession holds a special position of trust within society. As a consequence, society affords the profession certain privileges that are not available to members of the public-at-large. In return, the profession is supposed to make a commitment to society that its members will adhere to high dental ethics standards of conduct. It has always been expected that the dentists follow high ethical standards which have the benefit of the patient as their primary goal. In recognition of this goal, the education and training of a dentist has resulted in society affording to the profession the privilege and obligation of self- government. To fulfill this privilege, the high dental ethics standards should be adopted and practiced throughout the dental school educational process and subsequent professional career.
To come true to the professional expectations in the society, the dentists should possess not only knowledge, skill and technical competence but also those traits of character that foster adherence to ethical principles. Qualities of honesty, compassion, kindness, integrity, fairness and charity are part of the dental ethics education of a dentist and practice of dentistry and help to define the true professional. As such, each dentist should share in providing advocacy to and care of the underserved. It is urged that the dentist meet this goal, subject to individual circumstances, and the dentist should strive to do that which is right and good as per dental ethics.
The American Dental Association has documented the expected principals of dental ethics and professional conduct on the part of the dental professionals, the collection of which is known as ADA Code. Members of the ADA voluntarily agree to abide by the ADA Code as a condition of membership in the Association. They recognize that continued public trust in the dental profession is based on the commitment of individual dentists to high ethical standards of conduct.
The ADA Code has three main components:
The Principles of dental ethics, the Code of Professional Conduct and the Advisory Opinions.
The Principles of dental ethics are the aspirational goals of the profession. They provide guidance and offer justification for the Code of Professional Conduct and the Advisory Opinions. There are five fundamental principles that form the foundation of the ADA Code: patient autonomy, nonmaleficence (do no harm), beneficence, justice and veracity, The Code of Professional Conduct is an expression of specific types of conduct that are either required or prohibited.
Although dental ethics and the law are closely related, they are not the same. Ethical obligations may, and often do, exceed the legal duties. In resolving any ethical problem, dentists should consider the ethical principles, the patient’s needs and interests, and any applicable laws.
IMPORTANT PRINCIPALS OF dental ethics
1. Self Determination is one of the dental ethics: The dentist has a duty to respect the patient’s rights to self- determination and confidentiality.
This principle expresses the concept that professionals have a duty to treat the patient according to the patient’s desires, within the bounds of accepted treatment, and to protect the patient’s confidentiality. Under this principle, the dentist’s primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient’s needs, desires and abilities, and safeguarding the patient’s privacy as a part of dental ethics.
2. Patient Involvement: The dentist should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions as a part of dental ethics.
3. Patient Records: Dentists are obliged to safeguard the confidentiality of patient records. Dentists shall maintain patient records in a manner consistent with the protection of the welfare of the patient. Upon request of a patient or another dental practitioner, dentists shall provide any information in accordance with applicable law that will be beneficial for the future treatment of that patient.
4. Furnishing Copies of Records is one of the dental ethics: A dentist has the ethical obligation on request of either the patient or the patient’s new dentist to furnish in accordance with applicable law, either gratuitously or for nominal cost, such dental records or copies or summaries of them, including dental X-rays or copies of them, as will be beneficial for the future treatment of that patient. This obligation exists whether or not the patient’s account is paid in full.
5. Nonmaleficence (do no harm): The dentist has a duty to refrain from harming the patient. This principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle of dental ethics, the dentist’s primary obligations include keeping knowledge and skills current knowing one’s own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate.
6. Education: The privilege of dentists to be accorded professional status rests primarily in the knowledge, skill and experience with which they serve their patients and society. All dentists, therefore, have the obligation of keeping their knowledge and skill current as a part of dental ethics.
7. Consultation and Referral is one of the dental ethics: Dentists shall be obliged to seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience. When patients visit or are referred to specialists or consulting dentists for consultation:
1. The specialists or consulting dentists upon completion of their care shall return the patient, unless the patient expressly reveals a different preference, to the referring dentist, or, if none, to the dentist of record for future care.
2. The specialists shall be obliged when there is no referring dentist and upon a completion of their treatment to inform patients when there is a need for further dental care.
8. Second Opinions: A dentist who has a patient referred by a third party for a “second opinion” regarding a diagnosis or treatment plan recommended by the patient’s treating dentist should render the requested second opinion in accordance with this Code of dental ethics. In the interest of the patient being afforded quality care, the dentist rendering the second opinion should not have a vested interest in the ensuing recommendation.
9. Use of Auxiliary Personnel: Dentists shall be obliged to protect the health of their patients by only assigning to qualified auxiliaries those duties which can be legally delegated. Dentists shall be further obliged to prescribe and supervise the patient care provided by all auxiliary personnel working under their direction.
10. Personal Impairment: It is not as per dental ethics for a dentist to practice while abusing controlled substances, alcohol or other chemical agents, which impair the ability to practice. All dentists have an ethical obligation to urge chemically impaired colleagues to seek treatment. Dentists with first-hand knowledge that a colleague is practicing dentistry when so impaired have an ethical responsibility to report such evidence to the professional ethical and legal bodies of dental council.
11. Ability to Practice: A dentist who contracts any disease or becomes impaired in any way that might endanger patients or dental staff shall, with consultation and advice from a qualified physician or other authority, limit the activities of practice to those areas that do not endanger patients or dental staff. Thus he should avoid it as a part of dental ethics.
12. Postexposure, Bloodborne Pathogens:
All dentists, regardless of their bloodborne pathogen status, have an ethical obligation to immediately inform any patient who may have been exposed to blood or other potentially infectious material in the dental office of the need for post exposure evaluation and follow-up and to immediately refer the patient to a qualified health care practitioner who can provide post exposure services. The dentist’s dental ethics obligation in the event of an exposure incident extends to providing information concerning the dentist’s own bloodborne pathogen status to the evaluating health care practitioner, if the dentist is the source individual, and to submitting to testing that will assist in the evaluation of the patient If a staff member or other third person is the source individual, the dentist should encourage that person to cooperate as needed for the patient’s evaluation.
13. Patient Abandonment: Once a dentist has undertaken a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice as a part of dental ethics and the opportunity to obtain the services of another dentist. Care should be taken that the patient’s oral health is not jeopardized in the process.
14. Personal Relationships with Patients:
Dentists should avoid interpersonal relationships that could impair their professional judgment or risk tile possibility of exploiting the confidence placed in them by a patient as a part of dental ethics.
15. Community Service: Since dentists have an obligation to use their skills, knowledge and experience for the improvement of the dental health of the public and are encouraged to be leaders in their community, dentists in such service shall conduct themselves in such a manner as to maintain or elevate the esteem of the profession as a part of dental ethics.
16. Research and Development: Dentists have the obligation of making the results and benefits of their investigative efforts available to all when they are useful in safeguarding or promoting the health of the public as a part of dental ethics.
17. Patient Selection: While dentists, in serving the public, may exercise reasonable discretion in selecting patients for their practices, dentists shall not refuse to accept patients into their practice or deny dental service to patients because of the patient’s race, creed, color, sex or national origin as a part of dental ethics.
18. Patients with bloodborne pathogens:
A dentist has the general obligation to provide care to those in need as a part of dental ethics. A decision not to provide treatment to an individual because the individual is infected with Human Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus or another bloodborne pathogen, based solely on that fact, is unethical. Decisions with regard to the type of dental treatment provided or referrals made or suggested should be made on the same basis as they are made with other patients. As is the case with all patients, the individual dentist should determine if he or she has the need of another’s skills, knowledge, equipment or experience. The dentist should also determine, after consultation with the patient’s physician, if appropriate, if the patient’s health status would be significantly compromised by the provision of dental treatment as a part of dental ethics.
19. Emergency Service: Dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record as a part of dental ethics. Dentists shall be obliged when consulted in an emergency by patients not of record to make reasonable arrangements for emergency care. If treatment is provided, the dentist, upon completion of treatment, is obliged to return the patient to his or her regular dentist unless the patient expressly reveals a different preference as a part of dental ethics.
20. Overbilling: It is unethical for a dentist to increase a fee to a patient solely because the patient is covered under a dental benefits plan as a part of dental ethics.
21. Unnecessary Services: A dentist who recommends and performs unnecessary dental services or procedures is engaged in wrong as a part of dental ethics.
22. Marketing or Sale of products or procedures: Dentists who, as per dental ethics, engage in or employ auxiliaries in the marketing or sale of products or procedures to their patients must take care not to exploit the trust inherent in the dentist- patient relationship for their own financial gain. Dentists should not induce their patients to purchase products or undergo procedures by misrepresenting the product’s value, the necessity of the procedure or the dentist’s professional expertise in recommending the product or procedure as a part of dental ethics.
22. Professional Announcement: In order to properly serve the public, dentists should represent themselves in a manner that contributes to the esteem of the profession as a part of dental ethics. Dentists should not misrepresent their training and competence in any way that would be false or misleading in any material respect.
23. Advertising: No dentist shall advertise or solicit patients in any form of communication in a manner that is false or misleading in any material respect as a part of dental ethics.
24. Unearned, Non-health degrees: A dentist may use the title Doctor or Dentist, BDS, MDS, DDS, MS or any additional earned, advanced academic degrees in health service areas in an announcement to the public as a part of dental ethics. The announcement of an unearned academic degree may be misleading because of the likelihood that it will indicate to the public the attainment of specialty or diplomat status.
An unearned academic degree is one which is awarded by an educational institution not accredited by a generally recognized accrediting body or is an honorary degree. The use of a non-health degree in an announcement to the public may be a representation which is misleading because the public is likely to assume that any degree announced is related to the qualifications of the dentist as a practitioner as a part of dental ethics. Some organizations grant dentists fellowship status as a token of membership in the organization or some other form of voluntary association. The use of such fellowships in advertising to the general public may be misleading because of the likelihood that it will indicate to the public attainment of education or skill in the field of dentistry. Generally, unearned or non-health degrees and fellowships that designate association, rather than attainment, should be limited to scientific papers and curriculum vitae. In all instances, state law should be consulted. In any review by the dental council of the use of designations in advertising to the public, the council will apply the standard of whether the use of such is false or misleading in a material respect as a part of dental ethics.
25. Name of Practice: Since the name under which a dentist conducts his or her practice may be a factor in the selection process of the patient, the use of a trade name or an assumed name that is false or misleading in any material respect is unethical. Use of the name of a dentist no longer actively associated with the practice may be continued for a period not to exceed one year as a part of dental ethics.
26. Credentials in General Dentistry. General dentists may announce fellowships or other credentials earned in the area of general dentistry so long as they avoid any communications that express or imply specialization and the announcement includes the disclaimer that the dentist is a general dentist. The use of abbreviations to designate credentials shall be avoided when such use would lead the reasonable person to believe that the designation represents an academic degree, when such is not the case as a part of dental ethics.
NEEDS FOR THE FUTURE
Ethical and legal dilemmas and violations occur daily in the practice of dentistry. Occurrences of gross violations often surprise and appall those who conscientiously adhere to the profession’s ethical standards. While the association between dental ethics and patient care is an obvious and important one, ethical sensitivity and behavior are also necessary before students begin their clinical experiences.
The authors feel that the dental ethics courses should be offered, not as electives, but as a regular subject at the dental professional schools, as it is of paramount importance, particularly in the present situation when “most of the sources that transmit moral standards have declined in importance” or seem to have declined in the minds of most people.
Dental training programs are required to teach dental ethics and are charged with producing graduates who are “competent in the application of the principles of ethical reasoning and professional responsibility as they pertain to patient care and practice management.