CHAPTER 16 ETHICAL ISSUES IN COMMUNITY DENTAL HEALTH

WHAT DOES IT MEAN TO BECOME A PROFESSIONAL?

Have you been chosen by members of the dental or dental hygiene profession to become a dental professional? If so, those in the profession are telling you that they want to give you the opportunity to become their colleague. Have you thought about what it means to become a member of the dental profession? Are you aware of what distinguishes a dentist or dental hygienist from persons in other occupations or professions? Do you know what is expected of you as a student of the profession and as a future professional?

This chapter begins by describing the attributes of a profession and the implications for persons who wish to become a member of the dental profession. We describe the general moral obligations of the dental professional and then turn our attention to ethical issues that arise in community dental health. We briefly discuss the principles of biomedical ethics that apply to cases that arise in community dental health before presenting some cases to think about. We suggest that you read and discuss the cases with others before you read our analyses of them. Our hope is that this chapter will help you think more clearly about some of the problems that you are likely to encounter in your professional life. In particular, we hope this chapter will help you to think more clearly about responsibilities that extend beyond those you have to the individuals you will serve–responsibilities to the larger society. We hasten to add that we do not envision a set of professional responsibilities that are limitless. Rather, we hope to engage you in examining the nature of responsibility to others, to engage you in thinking about the limits of obligation, and to help you consider strategies that will effectively meet the profession’s responsibilities to prevent disease and promote the nation’s oral health.

Characteristics of a Profession

What distinguishes a profession from some other occupation? Do certain characteristics distinguish among occupations in ways that suggest that some are held to a higher ethical standard than others? Sociologists list as many as six attributes that emerge as an occupation becomes professionalized.¹ Briefly, an occupation is given authority (i.e., to make judgments on behalf of clients or patients, to determine the standards of practice, to set standards for admission to professional school and standards for accreditation of professional schools, to self-govern, etc.) in proportion to the amount and stability of the knowledge it takes to gain access to the profession and in direct proportion to the amount of harm potentially caused by incompetent practice. Power and privilege are awarded in exchange for the profession’s promise to place the rights of the client over self-interest and the rights of the society over the rights of the profession. To guide members of the profession in application of the promise, codes of ethics are developed. The canons of a code provide guidance to appropriate behavior in various circumstances and enable the profession to monitor itself. Codes are expanded as new issues emerge or as views of professional morality change. Professions value the powers and privileges granted by society and, through social organization, strive to maintain them.

Professions emerge over time, usually as a result of scientific advancement. Dentistry, for example, emerged and became more formalized in direct response to social conditions and scientific advances. In the mid-1800s some dentists made overstated claims about the benefits of treatment. The efforts to organize dentistry were based on a desire to protect the public from unscrupulous practitioners whose practices were not based on the latest scientific knowledge. The prohibitions against advertising–traced to codes of ethics developed by barristers in medieval England–were a direct effort on the part of the profession to control outrageous advertising practices and thereby make the profession more trustworthy.

The professionalization process has positive and negative outcomes. Let’s consider what might be referred to as the paradox of professionalism in contemporary society. On the one hand, professionalization and organization enable standard setting that protects the public–a positive outcome. On the other hand, professionalization creates a kind of monopoly that tends to increase costs and reduce access to care–a negative outcome. The challenge for any profession is to maintain a balance between these positive and negative outcomes. Failure to do so undermines public trust in the profession’s commitment–to place the interests of society above self-interest–and reduces society’s interest in helping the profession maintain the powers and privileges granted.

Implications for the Professional

By considering the attributes that distinguish each occupation or profession, we notice that dentistry possesses each of the essential attributes. Society has conferred powers and privileges on dentistry commensurate with the level of power and privilege reserved for the most highly professionalized occupations (e.g., law and medicine), thereby implying that society views the provision of dental care as essential for its health and welfare.

The possession of essential attributes implies that persons who wish to become members of the profession have the following responsibilities: (1) to acquire the knowledge of the profession to the standards set by the profession; (2) to keep abreast of changing knowledge through continuing education; (3) to make a commitment to the basic ethic of the profession–that is, to place the oral health interests of the patient above the interests of the professional and to place the oral health interests of society above the interests of the profession; (4) to abide by the profession’s code of ethics or work to change it if it is inconsistent with the underlying ethic of the profession; (5) to serve society (i.e., the public as a whole); and (6) to participate in the monitoring and self-regulation of the profession.

Power and privileges are granted to the profession on the basis of the assumption that each professional will take these responsibilities or obligations seriously. The profession has a right to expect that each individual who is chosen and then decides to become a dental professional will commit to these responsibilities.

Fulfilling these responsibilities is easier said than done. Professionals often find themselves in situations where personal and professional values conflict or where their professional obligations conflict. Many of the common conflicts are addressed in the American Dental Association’s Principles of Ethics and Code of Professional Conduct. The field of dental ethics attempts to prepare professionals to recognize, reason about, and effectively resolve the common dilemmas of the profession. In particular, dental professionals need to develop skills in ethical reflection that enable them to make good decisions about new problems that are likely to emerge during the course of professional life. Although membership in professional organizations is not legally required, no person can participate in monitoring and regulating the profession or influence the direction the profession takes by standing on the sidelines.

Because this book is devoted to issues of community dental health, this chapter focuses specifically on the obligations of the profession and the professional to serve society. Individual dentists meet that responsibility through service to the individual patient, to the patient’s family, to the community, and to the profession. The profession collectively meets that responsibility through a variety of efforts aimed at preventing disease and promoting the nation’s oral health.^* We not only advocate for obligations that go beyond the obligation to the individual patient, but also point out the limits of professional obligation. We are not advocating that dental professionals engage in the kind of selfless commitment to others that characterizes individuals such as Mother Teresa, but neither are we advocating that it is acceptable to exhibit the all-engrossing commitment to self exhibited by some of the more notorious examples of our time, such as inside-trader Ivan Boesky (who infamously asserted that “greed is good”). We are advocating that the dental professional has obligations to others that are somewhere on a continuum that has individuals like Mother Teresa on one end and those like Ivan Boesky on the other.

PRINCIPLES OF BIOETHICS

One way to think about the ethical obligations of dental professionals is through a popular approach focusing on three basic principles. In this approach, moral action guides are identified on the basis of duties or responsibilities to (1) show respect for persons; (2) avoid causing harm, prevent harm, remove harm, or provide benefit; and (3) act justly. These three bases for the duties are often referred to as the three principles of bioethics and are sometimes called the principle-based approach, or principlism. The principles of beneficence (including nonmaleficence) and justice were first enunciated by Frankena ² and popularized through their application to health care by Beauchamp and Childress.³

The distinctions among the duties to avoid harm, prevent harm, remove harm, and provide benefit are important, even though the duties may all be seen to arise out of the principle of beneficence. Frankena ² holds that duties to avoid and prevent harm are stronger or more basic than duties to remove harm or provide benefit. These are crucial distinctions for dental health professionals, suggesting that the first duty is to avoid injuring someone through malice or incompetence. After that, the duty to prevent dental disease would be stronger than the duty to help someone who has the disease, and the duty to remove the disease would be stronger than the duty to restore oral health. In fact, some do not consider restoring oral health as a duty, but rather the discretionary act of a virtuous professional.

The principle of respect for persons is based on the contention that individuals ought to be free to determine what will happen to their bodies. In the health care setting, this principle is the basis for the practice of informed consent, by which patients are given sufficient information to make an informed decision about whether to accept a proposed treatment–and the decision itself must be well considered and voluntary. Dentists are likely to consider this principle often as they consider patient requests for particular treatments and offer patients advice and options. The principle of justice questions what kinds of treatment to provide and for which patients treatment should be provided when resources (time, effort, and budgets) are limited. The principle of justice directs us to allocate or distribute resources in ways that are fair.

These principles should not be viewed as absolute, but rather as important principles to respect and follow in making decisions about ethical issues. For example, how should a dental professional respond to a patient who requests that all his or her teeth be extracted because it would save having to brush them every day? The dental professional ought to consider the request in light of the duty to respect the decision of the patient, drawn from the principle of respect for persons, while at the same time honoring the commitment to avoid causing harm and doing what is in the best interest of the patient (doing good). This example illustrates the potential and frequent conflict between important principles. How are we to resolve these conflicts, which are what make the consideration of ethical issues both interesting and difficult? One way to resolve a conflict between principles is to ask whether any particular principle is stronger than the others at issue. In the aforementioned example, we might ask whether the principle directing us to respect a patient’s request is more important (or stronger) than the principle directing us not to cause harm. A long history of protecting the right of individuals to make decisions for themselves may lead us to conclude that respect for persons takes precedent over all other ethical principles, but let’s look a bit further at the example. Before respecting the decision of a patient, we must be sure that the patient fully understands, and intends to make, the decision. Another way of saying this is that the dental professional must be sure that a patient has the mental capacity to make health care decisions.^* Once the dental professional determines that the patient is making a real, or autonomous, decision, a true conflict between principles exists. It is important to assess ethical situations in this way so that the ethical issues surrounding a case are addressed, rather than disagreement about the facts or other aspects of the case.

The dental professional appears to have two options in the example we have been discussing: respect the patient’s decision and extract the teeth as requested or refuse to extract the teeth on the basis that the harm caused by respecting the patient’s decision, even if it is autonomous, is too great. These kinds of conflicts are the source of debates about the so-called paternalistic model of the health care provider, in which the professional effectively overrides the autonomous decision of patients on the basis of a claim to superior knowledge of what is best for patients, regardless of whether the patient agrees. Such paternalism has been roundly attacked and is almost universally discredited. Nevertheless, it would be a paternalistic decision that many would support if the dental professional decided to override the autonomous decision of the patient to have all the teeth extracted. A way out may be to inform the patient that you respect his or her right of choice, but cannot violate your professional obligation to avoid actions that are harmful.

The third principle mentioned previously (i.e., the principle of justice) comes into play most frequently in considerations of allocating scarce resources, such as choosing which patients to treat when there is a shortage of dental services or dental care providers. Fair treatment is often the stated goal when such choices must be made, and reference to the principle of justice helps us decide what is fair. Fairness is another term for justice, and it can mean anything from equal treatment (the same for all) to equitable treatment (unequal but fair distribution). The principle of justice helps us to determine what method of distribution is most equitable. Methods can include distribution that is equal or based on need, merit, ability to pay, or a host of other factors. Justice requires that the method of distribution be justified and applied consistently. With these three principles, outlined here in general terms, ethical issues in dental care can be more effectively understood, examined, and, we hope, resolved. The case study analyses that follow attempt to apply these principles to real-life dental practice and the ethical issues that may arise in them.

CASES AND CASE ANALYSES

Case 1 The Jeremy Lee Case

Jeremy Lee is a 33-year-old African-American man. He suffers from a heart valve disease and had an aortic valve inserted 7 years ago. Since surgery, he has been receiving antibiotic therapy intermittently for infections. He has also been taking the anticoagulant warfarin to prevent clotting of the blood. This medication is necessary to prevent clots from forming and traveling through the blood-stream to distant organs. As a result of clots that lodged in small vessels of the brain, Jeremy has had several strokes. However, to date, the strokes have not caused any substantial deficit in his neurologic abilities. In part, his difficulties are related to his failure to consistently take his medications. He has been a Medicaid recipient from time to time, is currently unemployed, and is again on Medicaid.

Jeremy has five or six badly broken and neglected teeth remaining in the maxilla and about 12 teeth in the mandible. At least seven anterior teeth in the mandible are in good condition, in that they have no caries and no mobility. The gingiva is inflamed, but there is no pocketing more than 3 mm. There is some calculus, but a routine prophylaxis could improve the tissue. Jeremy has been given oral hygiene instruction but, according to the record, has shown no interest in improving his hygiene.

Because of his medical problems, Jeremy needs to be hospitalized to have his teeth removed. His health care team has to stop the warfarin, switch to heparin (which can only be given intravenously), and perform surgery under general anesthesia. After surgery, intravenous antibiotics must be continued for 48 hours and the warfarin resumed and monitored until appropriate levels are reached. The procedure requires five days of hospitalization, services of an oral surgeon (who will extract the teeth, contour the ridges, and prepare the tissues for a denture) and an anesthesiologist for 1.5 hours, recovery time, and other services, all at a cost of approximately $4,800.

Restoration of the teeth is out of the question because it would be costly and is not covered by Medicaid. As the oral surgeon, you need to decide whether to challenge the referring dentist’s decision to remove all the teeth in the mandible. Perhaps you should advocate leaving the seven sound teeth. Normally, this would be preferable because wearing a full lower denture is difficult. In a person as young as Jeremy, after many years of wearing a denture resorption would occur, making it increasingly more difficult to achieve a good fit. However, if Jeremy does not change his oral hygiene habits, a partial denture could accelerate the loss of the remaining teeth. Also, any infection could further complicate his health problems, and the teeth might need to be extracted at a later date, requiring hospitalization and further expense. If Jeremy is still on Medicaid, the added expense will be borne by society. On the other hand, the experience of wearing an upper denture might influence him to change his ways to avoid having a lower denture as well.

Should you remove all the teeth? Why or why not? What reasons would you give to support your position?

ANALYSIS

Professional-Patient Issues

This dilemma raises questions about the rights of patients who are unable to pay for their own care and must rely on public assistance. Should such patients have the same rights–to be informed of alternatives, to choose the preferred treatment, or to refuse treatment–as patients who are able to pay for the treatment? Should the oral surgeon, in deciding what to do, consider the fact that Jeremy Lee seems to have difficulty complying with the directives of his health care providers? In this case, no information is provided about the patient’s involvement in the treatment decision. Should we presume that the referring dentist achieved consent for the proposed treatment? The oral surgeon has a referral for extraction of all the teeth. Should the oral surgeon follow the directive of the referring dentist or overrule that decision and make a judgment as to the best interest of the patient? Although we might argue that the referring dentist should be consulted to determine whether the patient participated in the decision, it is interesting to explore whether to remove all the teeth, given the circumstances in this case.

One factor to consider is the limitations placed on Jeremy’s autonomy by his lack of financial resources. As a medical assistance recipient in most states, Jeremy is provided with relief from pain, swelling, and infection, but restorative services are usually limited. For example, he may be entitled to new dentures every 5 years. Or, if the dentist decides to leave the seven sound teeth, Jeremy would be eligible for a partial denture, but more functional and esthetic restorations (e.g., crowns and bridges) typically are not covered.

Although we might argue that many people would be likely to change their health care habits after receiving an upper denture, Jeremy has a history of noncompliance, at least as it relates to his general health. Failure to take his medications has life-threatening consequences. He has experienced these consequences without improving his compliance. Although there may be important questions as to whether Jeremy understands the consequences of his actions and is making an informed decision when he fails to comply, the surgeon cannot ignore his past noncompliant behavior because it is the single best predictor of his future actions. It is important to consider the range of possible reasons for lack of compliance: (1) the patient simply lacks understanding of the consequences, in which case additional education may be effective; (2) the patient lacks understanding of the consequences and has cognitive deficiencies or beliefs that make education difficult, in which case he may need a guardian or supervision if the provider cannot achieve comprehension; or (3) the patient may be consciously or unconsciously engaging in self-destructive behaviors because of depression, mental illness, or chemical dependency. In such cases, mental health interventions are needed.

People usually do not make major changes in health habits and behaviors. The oral surgeon needs to consider prior behavior in assessment of this case, especially in view of the patient’s serious medical problems.

Profession-Society/Community Issues

Conflict of Duties.

One thing that makes this dilemma so difficult is that dentistry has become much more focused on preservation of tooth structure and on restoration of function, rather than on extraction of teeth. The incredible decreases in dental disease we have witnessed in the last 20 to 30 years are responsible for this change of focus.^* But this has turned the focus from the prevention or removal of harm to the provision of benefit as the preeminent value of the profession. The idea that removing seven sound teeth in this case might be in the patient’s best interest, given his health habits and the significant health risks associated with a second surgery, seems to fly in the face of the profession’s emphasis on restoration of function and the idea that removing healthy teeth is in and of itself harmful.

In this case, it seems the surgeon would actually be “doing harm” to “prevent harm” that may come about if the teeth and surrounding tissue were left to fall victim to disease that is likely to result from the patient’s continued habits.

A second conflict of duties arises between the surgeon’s obligation to serve as an advocate of Jeremy’s interests and his obligation to the rest of society (e.g., not to spend a disproportionate amount of public money on this patient). Many situations involving public funds are predetermined. This is one situation where the dentist may be able to argue that the patient’s seven sound teeth have resisted decay and disease in the face of Jeremy’s health habits and are therefore less likely to become diseased in the future.

Rights of Jeremy Versus the Rights of Societyxs.

Some practitioners take the view that health care is a privilege rather than a basic right. They may believe that Jeremy should not be given any care that he cannot pay for. Other practitioners may take the view that there should be no discrimination on the basis of ability to pay and that the same benefits should be available to all irrespective of ability to pay. Such differences in views are often grounded in deeply held convictions. Rather than arguing which is the “right” view, it may be helpful to explore the beliefs that are at the root of these conflicting ideas. Many of us have been socialized to believe that anyone could take care of himself or herself, if only he or she would put forth the effort to do so. Even though we may recognize that such a view is only partially true, such ideas are rooted in concepts of individualism and the puritan ethic, values that underlie much of American history and culture.^* Irrespective of personal perspective, American society currently provides basic care for those who are poor and disadvantaged, but the benefits provided do not represent optimal oral health.

Rights to Oral Health Care Versus Rights to Medical Care.

Medicaid programs often do not cover any adult dental care or are restricted to emergency services. Sometimes episodic procedures for relief of pain and infection are provided, but generally dental care is viewed as elective, rather than as an integral part of an individual’s overall primary health care. For example, before the implementation of the Oregon Health Plan in 1994, a patient could have a benign mole removed from the neck, but could not have decayed teeth restored.⁴ When the Oregon Health Plan created a state-approved list of medical and dental health services by an open public process, many dental services previously excluded from the Medicaid list of benefits were suddenly included.^* “Oregon now has one of the most generous dental Medicaid benefit packages in the country, including coverage for services such as endodontic treatment, scaling and root planing, along with basic preventive, restorative and prosthodontic services. Cast crowns and bridges are included with limitation. Further, over 100,000 individuals not previously covered by Medicaid were brought into the plan and provided dental coverage.”⁴ From the perspective of increasing access to dental care, the profession may want to reconsider the wisdom of advocating for the separation of medical and dental benefits.