1: Ethical Principles – Informed Consent

Case 1
Ethical Principles – Informed Consent

Medical History

There are no significant issues in the medical history and the patient takes no prescribed or over‐the‐counter medications.

Dental History

There are no records or memory of the patient having been seen for dental care since she left her country 15 years previously. The chief complaint as related by her daughter appears to be halitosis and occasional discomfort when chewing and taste alteration. Patient nods yes to brushing every day but shakes her head no when shown floss and other interdental biofilm removal aids.

Gingival tissues are red in color, with generalized edematous tissue. The tissue readily bleeds on probing and probing depths in the posterior areas are generally 4 and 5 mm. There are moderate biofilm and calculus deposits. There appears to be occlusal decay on several molars in all four quadrants. Gingival recession is 2 mm and is generalized.

Social History

The daughter reports her mother does not smoke or drink but eats a diet high in carbohydrates, indicative of some cultural recipes she continues to prepare from her country. The family depends on her to make the best sweets for dessert that they enjoy throughout the day. Her diet is strongly influenced by culture. Although fresh foods are a part of daily consumption, so too are dishes and snacks with high concentrations of sugar.

Dental Hygiene Diagnosis

Problems Related to Risks and Etiology
Periodontal disease Inadequate biofilm control and preventive dental visits
Caries Inadequate biofilm control and diet high in carbohydrates
Halitosis and foul taste Periodontal infection
Discomfort chewing Presence of carious lesions

Planned Interventions

Clinical Education/Counseling Oral Hygiene Instruction
Full mouth series of radiographs Needed for diagnosis Explain the results of the series
Scaling and root planing by quadrant Periodontal infection present Etiology and progression of periodontal disease
Homecare instructions Importance of home care Modified Bass brushing, flossing, and fluoride rinse
Fluoride treatment Needed for remineralization Action of fluoride and home fluoride rinse
Nutritional advisement Carbohydrates contribution in development of caries Reduction in intake of carbohydrates
Arrange for a health care professional Importance of understanding treatment plan and home care Engage a professional interpreter to relay all interactions
Restorative appointment for fillings As determined by diagnosis Stress continued appointments until completion
Evaluate tissue response in 6 weeks Document tissue response Adjust instructions as needed
Periodontal maintenance every 4 months Monitoring treatment, host response, and home care Continue as instructed or adjust treatment as needed


All health‐care providers have an ethical obligation to treat the public applying defined principles of action. This is a result of the knowledge and skills achieved to be licensed to deliver care. The public respects this and seeks out this expertise. The public expects the highest levels of care and the health‐care provider is obligated to meet these expectations.

Autonomy is an ethical principle that addresses the patient’s right to make an informed decision about their care. Affording autonomy to a patient gives them the ability to be self‐governing and in turn they can choose what is relevant to their needs. Autonomy gives individuals permission to make decisions regarding their health care. To do this they must be given explanations about treatment choices and consequences of those and the consequences of rejecting the treatment services (Beemsterboer 2010).

The American Dental Hygienists’ Association (ADHA) lists autonomy, beneficence, nonmaleficence, justice, fairness, societal trust, veracity, and confidentiality as core values for practice. All these are the principles the dental hygienist incorporates into care (ADHA 2016a).

The dental hygienist is now faced with an ethical dilemma. A dilemma exists when two or more principles are in conflict. To ensure autonomy for the patient, the etiology of the infection needs to be explained and understood by the patient in order to accept the treatment plan (Figure 11.1.2).

Illustration displaying an oblong at the center labeled I DON’T UNDERSTAND surrounded by oblongs labeled Hindi ko maintindihan, No entiendo, Non capisco, Je ne comprends pas, Mujhe samajh nahin aata, etc.

Figure 11.1.2: If you can’t understand a patient’s response then they can’t understand you.

The teenage daughter may not have understood the treatment plan sufficiently to relay it to the patient. In fact, the patient’s LEP has probably contributed to her not seeking professional care.

Having a patient sign a consent form without her understanding the financial obligation, the benefits, the risks, the possible outcomes, and giving her a chance to ask questions can be considered Battery. (A dentist who does something without consent on a patient is considered to have committed Battery. In this example, although the patient signed the consent form, they did not give actual consent due to the patient not understanding the form. Any procedures carried out on this patient by the health‐care professional would be considered Battery. Having them sign the form itself is not Battery.) In this case the clinician is practicing below the standard of care professionally and is violating legal protections and ethical principles (Figure 11.1.3).

Illustration displaying an oblong at the center labeled I Consent surrounded by oblongs labeled Yo consiento, Wo tongyi, Toi dong y, J’accepte, Ikh tsushtimen, Ya soglasen, Mainu sahimati, Naneun dong-ui, etc.

Figure 11.1.3: A patient cannot give informed consent unless they know the facts and can ask questions.

The dilemma has two principles in conflict: the patient’s autonomy and the responsibility of beneficence to do good. Doing good for the patient would involve taking actions to remove existing harm. A model for analyzing a dilemma follows the steps of gathering facts, identifying the ethical principles in conflict, listing alternatives, selecting, justifying the action, acting on the decision, and finally evaluating the decision. If the dental hygienist accepts the daughter as interpreter, the hygienist would not know whether everything was related to the patient in a satisfactory manner. The dental hygienist does not know if anything may have been omitted or misunderstood. The dental hygienist cannot be sure that the daughter has told her mother everything about her needs. If treatment proceeds with exposing x‐rays and scaling there cannot be a certainty that this is what the patient understood or if her questions were answered correctly. The dental hygienist wants to afford beneficence by doing good for the patient with home care instructions, scaling, and recommending restorations.

Proceeding with any treatment without certainty that the patient understands is unethical and the patient’s autonomy is denied. If the dental hygienist doesn’t proceed the treatment could be delayed considerably and the patient would also continue to experience discomfort.

An important obligation of all health‐care providers is to act within the confines of law. Without informed consent the patient does not experience autonomy. Patients have not given permission for treatment and so the crime of Battery can be claimed. When analyzing a dilemma, the law takes precedence and the standard of care should be respected.

Lack of informed consent is noted in civil and criminal cases against providers in dentistry. Patients should understand treatment outcomes and all risks possible including having no treatment at all. The health‐care provider must ensure the patient receives all pertinent information about planned care. Patients should have their questions answered truthfully without prejudice or exclusions. This is standard practice without exception (ADHA 2016b). It is also necessary to document this as a permanent part of the patient’s record. Documentation is first of all data collected for the definitive diagnosis. The ADHA has published the document, Standards for Dental Hygiene Clinical Practice.

American Dental Hygienists’ Association

Standards for Clinical Dental Hygiene Practice 2

Standard 1 Assessment

The collection and analysis of systematic and oral health data in order to identify client needs.

Standard 2 Dental Hygiene Diagnosis

The identification of an individual’s health behaviors, attitudes, and oral health care needs for which a dental hygienist is educationally qualified and licensed to provide. The dental hygiene diagnosis provides the basis for the dental hygiene care plan.

Standard 3 Planning

The establishment of realistic goals and the selection of dental hygiene interventions that can move the client closer to optimal oral health.

Standard 4 Implementation

The act of carrying out the dental hygiene plan of care. Care should be defined in a manner that minimizes risk, optimizes oral health, and recognizes issues related to patient comfort including pain, fear, and/or anxiety.

Standard 5 Evaluation

The measurement of the extent to which the client has achieved the goals specified in the dental hygiene care plan.

Standard 6 Documentation

The primary goals of good documentation are to maintain continuity of care, provide a means of communication between/among treating providers, and to minimize the risk of exposure to malpractice claims.

For the language barrier, there are two options in this case. The dental office could have a team member who can speak the language and relay this information or the clinician can use a call service, at no charge to the patient, which specializes in the practice of interpreting for health‐care providers. Some of these services are available 24 hours a day. It is poor risk management to use a family member as an interpreter. (On May 13, 2016 the Department of Health and Human Services (DHHS) formally adopted final changes to section 1557 of the Affordable Care Act ACA. The new rules took effect on July 18, 2016 and will be codified as 45 CFR part 92. These changes are sweeping in scope as they apply to “every [federal] health program or activity, any part of which receives Federal financial assistance.” The final rule prohibits the use of adult family members and friends as medical interpreters. However, the final regulations allow two exceptions to this general rule. First, adult family members and friends may be used as medical interpreters in an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no qualified interpreter is immediately available. (Note: since most leading national telephonic and video remote interpreting companies can make qualified interpreters available in hundreds of languages within seconds, this exception should be regarded as limited.) Second, adult family members and friends may be used as medical interpreters where the LEP person “specifically requests that the accompanying adult interpret or facilitate communication and the accompanying adult agrees to provide such assistance.” However, the rule makes plain that providers are not relieved of their legal duty to provide a qualified medical interpreter where an LEP patient elects to use an adult family member or friend since even then, “reliance on that adult [family member or friend must be] appropriate under the circumstances.” The treatment plan must not go forward until these qualifications are met. The patient must be allowed to understand and choose to accept or reject the plan. The dental hygienist should reschedule the patient until these are all satisfied.

There is a Code of Ethics for Dental Hygienists and a Code of Ethics for Dentists (ADA 2016; ADHA 2016a). Several of the concepts, core values, and principles are the same. They both include autonomy, beneficence, nonmaleficence, veracity, and justice. The American Dental Association’s (ADA) code makes reference to auxiliaries for dentists. They are reminded that they are obliged to protect the health of their patients by only assigning to qualified auxiliaries those duties that can be legally delegated. The ADHA further includes the fundamental principle of Universality, which expects that if one individual judges an action to be right or wrong in a given situation, other people considering the same action in the same situation would make the same judgment. The principle of Complementarity recognizes the existence of an obligation to justice and basic human rights. In all relationships, it requires considering the values and perspectives of others before making decisions or taking actions affecting them” (ADHA 2016a). ADHA’s principle of Community is the concern for the bond between individuals, the community, and society in general. It leads to the preservation of natural resources and inspires a sense of concern for the global environment. Responsibility is the recognition that there are guidelines for making ethical choices and the acceptance of responsibility for knowing and applying them. Dental hygienists accept the consequences of their actions or the failure to act and are willing to make ethical choices and publicly affirm them. Ethics, in the code, are considered to be the general standards of right and wrong that guide behavior within society. As generally accepted actions, they can be judged by determining the extent to which they promote good and minimize harm. Ethics compel dental hygienists to engage in health promotion/disease prevention activities.

The ADHA lists as core values, individual autonomy, and respect for human beings, that is, people have the right to be treated with respect. They have the right to informed consent prior to treatment, and they have the right to full disclosure of all relevant information so that they can make informed choices about their care. Confidentiality, in respect of client information and relationships, is a demonstration of the value placed on individual autonomy. Dental hygienists acknowledge their obligation to justify any violation of a confidence. Societal Trust is the principle in which dental hygienists value client trust and understand that public trust in their profession is based on individual actions and behavior. Nonmaleficence states that dental hygienists accept their fundamental obligation to provide services in a manner that protects all clients and minimizes harm to them and others involved in their treatment. Beneficence declares that dental hygienists acknowledge they have a primary role in promoting the well‐being of individuals and the public by engaging in health‐promotion/disease‐prevention activities. When referring to Justice and Fairness, dental hygienists value justice and support the fair and equitable distribution of health‐care resources. They believe all people should have access to high‐quality, affordable oral health care. The last core value for dental hygienists is Veracity, wherein dental hygienists accept their obligation to tell the truth and expect that others will do the same. They value self‐knowledge and seek truth and honesty in all relationships.

Take‐Home Hints

  1. Autonomy is a right afforded to patients.
  2. Dental hygienists must practice according to federal, state, and local statutes and regulations.
  3. Dental hygienists have ethical responsibilities to all patients.
  4. When faced with a dilemma: gather the facts, list the ethical principles in conflict, list the alternates, and act on this decision.

Jul 18, 2020 | Posted by in Dental Hygiene | Comments Off on 1: Ethical Principles – Informed Consent

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