Ethics is defined as “of or relating to moral action, conduct, motive or character; as ethical emotion; also treating of moral feelings, duties or conduct; containing precepts of morality; moral. Professionally right or befitting; conforming to professional standards of conduct” . Decisions on which type of material to use or how to treat a certain situation are guided by treatment protocols. How to decide a fair, just disposition of an ethical situation or dilemma, however, will keep one up for nights. It is the dentist’s responsibility and duty to maintain a professional demeanor that includes consideration, respect, and understanding toward fellow colleagues, employees, patients, and their families. To gain a foundation from which the dentist may formulate thought and, it is hoped, a proper decision, the American Dental Association (ADA), FDI World Dental Federation, and many other groups have developed codes of ethics. These codes of ethics should guide the dentist in his or her decision making at all levels of practice, in one’s professional career, and even in one’s personal life. But, as will be pointed out, decision making cannot occur in a vacuum, only considering the various codes of ethics. The other pillars of decision making must also be taken into consideration: dental law, risk management, and practice management (public relations).
Throughout these codes, the following principles may be found: patient autonomy, nonmalfeasance, beneficence, justice, veracity, and fidelity.
Patient autonomy gives the patient, or the patient’s legal guardian, the right to confidentiality and self-determination; in this case, the right to decide a course of treatment. Chapter 8 discussed the five levels of a patient’s capacity to participate in that right to decide. The lower the level of capacity to understand, the more the dentist must take care in his or her informed consent to maintain patient autonomy. The dentist may be inclined or even forced to ask if the patient is in need of guardian-like help from friend or family (see True Case 19). Patient autonomy intersects with informed consent. Giving a proper informed consent with all relevant, necessary information for an informed decision is a major facet in the patient’s right to self-determination and, hence, maintenance of patient autonomy. Patient autonomy also intersects with the doctor–patient relationship and the Health Insurance Portability and Accountability Act (HIPAA) in its principles of confidentiality. By respecting the patient’s privacy to personal information, with the understanding that such personal information belongs to the patient and should not be made known to others without the patient’s consent, the dentist is able to also adhere to a trusting doctor–patient relationship and HIPAA laws .
With the development of cosmetic dentistry, there has been an increase in the patient’s awareness of his or her smile. Dentists also have promoted improving the patient’s smile through cosmetic dentistry. The question becomes, “How much should a dentist pursue or promote the improvement of a patient’s smile before the dentist is intruding into the patient’s autonomy?” To keep the patient’s autonomy intact, when the dentist perceives a cosmetic need, he or she must keep the discussion educational to properly inform the patient of cosmetic dentistry’s capabilities. It should not become a commercial, merchant-like sale. Not all patients want nor have to have the perfect smile. Therefore, the dentist must not take advantage of an unsuspecting, unknowledgeable, trusting patient for the purpose of advancing the dentist’s own well-being or income.
Nonmalfeasance is the principle that creates a duty to cause no harm to the patient. Nonmalfeasance may be seen throughout the practice of dentistry. First and foremost, the dentist must know his or her limitations of practice and stay within those limitations and the standard of care. The dentist should avoid unlearned and experimental treatments without a true research-level informed consent. In attempting to try new procedures, the dentist must take the time and make the effort to be properly trained such that the risk of harm to the patient is at a minimum. It is clearly unethical to try an unproven treatment on an unsuspecting, trusting patient to whom the risk of harm is greatly increased. It is also the duty of the dentist to properly refer the patient when the needed treatment is beyond the dentist’s capabilities. By referring the patient, the standard of care is also properly followed. In a situation where the patient refuses the referral, an informed refusal then takes place, as discussed in Chapter 8. This situation becomes even more stressful for the dentist when the patient states, “Just do the best you can, Doc.”
TRUE CASE 30: Patient doesn’t want referral
A patient came to a dentist who was on her insurance company’s list of participating dentists. The patient was in need of endodontics on a 2nd molar, which already had a clinically viable porcelain-to-metal crown. When the dentist told the patient that he wanted to refer her to an endodontist, the patient became angry with the dentist, of whom she thought very highly, because he would not treat her. The dentist unsuccessfully tried to explain the complexity of the situation. The patient, on the other hand, told the dentist of the trust she had in him and that he had already successfully performed a root canal for her in the past. The dentist performed the root canal but was highly stressed, though it ended with a positive result. The result could have easily resulted in a bad outcome on many levels.
Law and ethics also intersect in the case of abandonment of a patient. Abandonment of a patient, more times than not, results in injury to the patient due to delayed treatment; therefore, it is unethical. When a patient is under the care of the dentist, the dentist must take every precaution to cause no harm to the patient.
Harm is not only physical but may also be seen as emotional when personal relationships develop between dentist and patient. A personal relationship with a patient has long been frowned upon, due to the possibility of either party exploiting the relationship. It truly infringes on the patient’s confidence in the dentist and impairs the dentist’s professional judgment. Legally, it also can lead to alleged sexual harassment, which is not covered by malpractice insurance, as noted previously.
Nonmalfeasance may also be found to be violated by a dentist promoting his or her experience as being more extensive than what it really is. A true informed consent concerning a procedure that is new to the dentist may not be found to be valid if the dentist did not inform the patient that it is a procedure new to the dentist and that he or she is doing it for the first time. This would obviously affect a reasonable person’s autonomous decision making.
TRUE CASE 31: I don’t want my teeth
A patient needing extensive care, including periodontal surgery, extractions, endodontics, and restorative work, came into the dentist’s office wanting to have all her teeth removed and dentures made because she was tired of all the pain and expense of treatment. She had previously undergone extensive treatment 10 years prior and did not wish to do it again. There were many easily savable teeth that would have been excellent for partial dentures. The patient became adamant that all teeth should be removed. The dentist tried several different ways to explain that what she was requesting was not in her best interest. She then told the dentist to either see the situation her way or she would go else where. The dentist proceeded to accommodate the patient. At the appointment to reline her immediate denture, the patient profusely cried that she should have listened to the dentist. The dentist felt very bad that he was not able to communicate better to help the patient understand the situation.
It may have been better for the dentist to refuse the patient, if a patient’s autonomy extends to self-injury. Ethically, but not legally following treatment protocols within the standard of care, the dentist should have thought about possibly denying the patient treatment.
Beneficence is the principle where the dentist has a duty to promote the patient’s well-being. This can be easily seen in informed consent, treatment planning, and proper referrals. But it is also found in providing treatment in a timely manner regardless of the method of payment. Once a dentist has undertaken a procedure, he or she must proceed to a point in treatment so as to not cause harm, as discussed previously, but also to promote the well-being of the patient. This does not mean that treatment must be provided for free when the patient will not meet his or her agreed financial responsibilit/>