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Ethical considerations for the oral healthcare of frail elders
INTRODUCTION
Meeting care needs is a central ethical concern in healthcare. (As there is no commonly accepted pattern of differentiating the terms ethical and moral, they will be treated as synonyms in this chapter.) Significant lapses in care may even be considered a moral failing for those who value health and healthcare as a social good (Dharamsi and MacEntee, 2002). As the chapters of this book unfold, we will see that meeting the oral healthcare needs of frail elders is complex and the supports required to mitigate potential lapses in care are vast. The purpose of this chapter is to focus on key ethical dimensions within this unique realm of healthcare. While one-on-one decisions about the health needs and clinical care of individual patients will feature prominently, we recognize that collective decisions, such as those that establish priorities for resource allocation and health education, are also integral to meeting health needs. In our view, decisions made about healthcare have ethical dimensions because outcomes ultimately affect the human condition—whether as an individual or as part of a larger social group.
Since the realm of healthcare ethics is so vast, we will not attempt to provide an ethical framework sufficient to examine all dimensions of care. Rather, we will use clinical scenarios to elucidate a number of key themes and challenges that are commonly encountered when dental professionals attend to the needs of frail elders.
The chapter has three sections. First, we provide a clinical context for the chapter by describing three scenarios. Second, we respond to relevant ethical themes arising from the cases where we address: patient autonomy as it relates to informed choice and capacity; unclear treatment outcomes; and neglect and abuse. Finally, we raise the broader issue of social responsibility, considering the role of dental professionals, implications for education, and the larger role of society in responding to the oral healthcare needs of frail elders.
CLINICAL CONTEXT
Issues of chronic care and aging have been debated and discussed by ethicists for some time (Daniels, 1991; Callahan, 1995), although both applied and theoretical bioethics have focused primarily on issues of acute care and medical research. The literature is replete with ethical frameworks and strategies for examining and responding to the complex and dramatic issues of acute care. More recently, attention is being directed toward ethical issues arising in chronic care, particularly among vulnerable underserved groups such as the aged (WHO, 2002; Pedersen et al., 2008). Our focus is on identifying morally relevant and unique features of oral health and oral healthcare among frail elders.
Oral health is an essential part of daily comfort, hygiene, and general health (MacEntee et al., 1997). A defective dentition can dramatically disturb eating, speaking, general appearance, and comfort, whereas poor oral hygiene raises significant social and personal concerns for most people (MacEntee, 2007). Pain and discomfort, no matter what the source, impede enjoyment, comfort and dignity. For people who are frail and dependent, the need for oral care typically ranges from daily personal care to complicated therapeutic and restorative treatments. It follows then that effective care requires a coordinated response to address the challenges of “hands-on care” along with the policy and organizational processes supporting care. The following scenarios introduce a number of the issues, with a short description of relevant ethical themes. Typical of real challenges, the scenarios consider the care of individuals residing in a variety of living arrangements, and who represent a range of personal abilities and support.
Mr. Scholten’s clinical scenario
Mr. Scholten, who is 83 years old and financially secure, lives in a residential care facility because of severe rheumatoid arthritis. His only other significant medical issue is hypertension. He and his family noticed his teeth deteriorate over the past 2 years coincident with his increasing difficulties with mobility and managing his own personal care. He had no dental pain or discomfort; however, his family encouraged him to consult Dr. Green, the dentist who attends the facility. He was motivated to accept this advice because his broken teeth were becoming an embarrassment when dining and participating in other social activities. On the day of his appointment, his blood pressure was 180/115 mmHg. He reported that he used to take blood pressure medications on his physician’s orders but stopped several years previously. He told Dr. Green that, “I have lived a good long life, and I pray for good health. But, it is really in God’s hands. I am not going to take medications anymore.” The examination revealed a healthy periodontium, generally, but several teeth had active caries. Dr. Green recommended that certain teeth be extracted, and that he needed fillings in several others, and possibly a removable partial denture in both jaws to replace missing teeth. He also explained that the treatment would not be overly invasive, but that he would be uncomfortable providing it when the blood pressure was so high.
Commentary on Mr. Scholten
The ethically relevant features of Mr. Scholten’s situation center on his autonomy and the choices for care in light of the potential risks and benefits of dental treatment. He wants to improve his quality of life by having his dental concerns addressed, but he also wants to avoid medications. This raises a serious ethical conflict for the dentist. In the interest of his patient’s autonomy, is it appropriate for the dentist to put Mr. Scholten at risk by rendering treatment in the presence of uncontrolled hypertension? Might this be considered substandard care in the context of appropriate clinical practice? On the other hand, if Mr. Scholten is fully informed about the risks and wants the dental treatment, is there moral justification for the dentist to simply refuse?
Mr. Jackson’s clinical scenario
Mr. Jackson is an 82 year-old retired farmer and widower. Since moving to the city 10 years ago to be closer to his children, he has been a semiregular patient at a local dental clinic. Recently, he attended the clinic for a routine examination and hygiene. Normally, he is very talkative, bright, and smartly dressed. On this visit, however, Dr. Smith, his dentist, noticed that he was dishevelled and very distracted. He found also that Mr. Jackson had an abscessed molar tooth with a vestibular swelling and tenderness on palpation. He knew that the tooth would be difficult to extract and would require another appointment. In the meantime, Dr. Smith prescribed an antibiotic to reduce the risk of cellulitis. Although he had concerns about Mr. Jackson’s well-being and state of mind, his patient seemed to understand the explanation about the tooth. Therefore, he dismissed Mr Jackson’s appearance as simply a consequence of the early morning appointment.
Mr. Jackson did not appear for the follow-up appointment, and when the receptionist phoned him, Mr. Jackson said, “I guess I must have forgotten … I forget a lot of things these days.” They rebooked the appointment for the following week, but again, Mr. Jackson failed to keep it, and he sounded confused and upset when the receptionist phoned again. He complained that Dr. Smith did something to his tooth because it was painful and his face was swollen. Consequently, he did not want Dr. Smith to do any more harm and refused another appointment.
Commentary on Mr. Jackson
Autonomy is also the primary issue associated with Mr. Jackson. However, in this case, there is doubt about Mr. Jackson’s capacity to understand and make decisions about his health status and treatment needs. Dr. Smith initiated an appropriate course of treatment to benefit Mr. Jackson, but the lack of follow-up could have serious consequences. Dr. Smith will now have to engage the appropriate substitute decision maker if Mr. Jackson truly lacks the capacity.
Mrs. Alders’ clinical scenario
Mrs. Alders is a 93-year-old patient with multiple health problems, including dementia and chronic obstructive pulmonary disease. Although she has been cared for by her family for the past 13 years, her 71-year-old daughter can no longer cope with the increasing demands associated with the dementia. Mrs. Alders was admitted recently to a residential care facility approximately 100 km from her daughter’s home. On admission to the facility, a dental screening revealed very poor oral hygiene, rampant caries, and extensive structural breakdown and mobility of almost all of her remaining 16 teeth. There were no obvious signs of dental pain or distress during the screening examination. She can eat soft foods without difficulty but needs help to carry the food from the plate to her mouth. Her mouth is very dry most of the time, likely a side affect of multiple medications. Combative behavior due to the dementia makes it very difficult for care-aides to clean her teeth or for Dr. West, the facility’s attending dentist, to provide the dental treatment. Dr. West offered to extract all of Mrs. Alders’ teeth under general anaesthesia in a hospital 45 km from the facility. However, Mrs. Alders would have to travel to the hospital for an examination by an anesthetist before the surgery could be scheduled, and she or her family would have to pay directly for the transport and costs related to examination and treatment. Her daughter refuses to consent because she does not want her mother to be distressed by the extractions or the multiple visits to hospital.
Commentary on Mrs. Alders
Mrs. Alders is representative of many dependent frail elders whose oral health deteriorates and poses a threat to her general health and well-being. She is unable to attend to her daily mouthcare, and apparently, the nursing staff and her daughter cannot provide this care for her. In addition, access to a hospital for dental surgery is difficult, and the cost and complexity of dental care is burdensome for her family. This raises ethical questions within the larger social context about how oral healthcare is organized, managed, and financed. Where, for example, does the responsibility lie to facilitate her daily mouthcare? What is appropriate care for someone who is cognitively disabled and almost completely dependent on others for basic needs? Is it appropriate to extract her remaining teeth or could the loss of so many teeth increase Mrs. Alders’ distress and well-being. Alternatively, is it ethically acceptable to withhold dental treatment until she becomes distressed and impaired by toothache or acute infection?
RESPONDING TO ETHICAL ISSUES
The dual phenomena of an aging population with a seemingly endless array of techniques to improve and prolong life have prompted discussions about ethical decisions bearing on the terminal stages of frailty. Advance directives, withholding and withdrawing life-sustaining treatment, and assisted suicide are among the more serious issues that challenge families, clinicians, ethicists, and lawyers to examine the value of human life in a medically sophisticated environment. The responsibility of dentists for providing care toward the end of life in the midst of severe frailty also requires serious thought about the value placed on the care of people who are debilitated or dying, and on the ethical dimensions of decisions influencing this care.
Typically, ethical problems in healthcare arise when a decision must be made in the context of an unresolved moral tension between alternative choices (Purtilo, 1993). Mr. Scholten, for example, challenges the dentist with the struggle between his wish to avoid medications and the dentist’s concern about the risks of treatment impacting dangerously on uncontrolled hypertension. Although intuitive judgments are made everyday by clinicians, ethical problems may require a more systematic approach to support moral decisions (Ozar and Sokol, 2002). In the case scenarios we describe, determining a morally defensible course of action requires that various ethical approaches be examined in the context of patient needs and values as well as clinical best practices. This process can be difficult when there are divergent opinions about the best theoretical approaches to a given question or dilemma (Baylis et al., 1995). Indeed, many ethical problems have multiple conflicting solutions with no obvious resolution (Ozar and Sokol, 2002).
Standards of ethics in contemporary healthcare arise for the most part from perspectives grounded in a variety of theories and strategies. They help to frame appropriate responses to a variety of problems, such as delivery of care, biomedical research, codes of professional conduct, organizational ethics, and resource allocation. This theoretical orientation not only affects the ways in which we analyze and resolve particular problems but it also influences issues that we recognize as morally significant and the solutions that are morally acceptable (Baylis et al., 1995).
The most prominent approaches taken in contemporary bioethics are supported by a variety of ideas, including consequence-based ethics, deontological (rights and duties oriented) ethics, virtue ethics, and feminist ethics (Baylis et al., 1995; Kluge, 1999). Consequentialist theories, such as utilitarianism, evaluate the moral appropriateness of an action by determining the moral desirability of its consequences. Although there are many variations, the basic principle of utility requires that we would “act in such a way as to maximize the balance of good over harm for the greatest number of people” (Kluge, 1999). In contrast, deontological theories determine the moral rightness or wrongness of an action in terms of whether or not it adheres to fundamental moral rules that can be justified independently of consequences (Baylis et al., 1995). There is great debate about which moral rules or principles are consistently justifiable in healthcare. Current approaches recognize that a number of relevant principles must be considered and balanced against each other depending on the situation (Kluge, 1999).
Central to modern biomedical ethics are the four principles “nonmaleficence,” “beneficence,” “respect for autonomy,” and “justice” (Beauchamp and Childress, 2001). This set of principles provides a useful framework through which to analyze and consider ethical issues in healthcare. Each principle indicates a duty related to a specific choice of behavior or action in the absence of a conflicting duty. In keeping with the Hippocratic tradition, nonmaleficence indicates that we “do no harm,” while beneficence requires removal and prevention of harm, and promotion of good. The high value placed in most cultures on respect for human dignity and self-determination leads to respect for a patient’s autonomy and wishes. Finally, justice is concerned with the fair distribution of benefits and burdens in society. In healthcare generally, but particularly when considering vulnerable populations, attainment of accessible and adequate care reflects a reconciliation of various tensions and responsibilities in the pursuit of justice. Overall, the four principles are guides that leave room for the development of more context-specific rules and policies. The American Dental Association’s Code of Ethics provides a useful example of how these principles can be applied in relevant ways to dentistry and oral healthcare (ADA, 2005).
Virtue ethics provides a way of thinking about ethics where actions are not governed by obligations or rules of conduct. Virtues represent a “habit of acting, perceiving, and valuing in the best way possible for the situation” (Ozar and Sokol, 2002). Moral virtues are character traits with high moral value. Applied to healthcare, virtue ethics is concerned with recognizing and developing character traits and daily habits that lead to right actions without careful reflection (Ozar and Sokol, 2002). Virtues such as benevolence, integrity, and compassion are often identified in codes of ethics to exemplify what is valued by the profession as a whole. They represent what it means to be a “good dentist” and offer evidence of moral competency (Welie and Rule, 2006).
Feminism considers the social experiences of women as distinct from the experiences of men, and feminist ethics offers approaches for responding to the distinctions that challenge the dominant male traditions (Tong, 1995). It has been invaluable in bringing attention to the impact of traditional power arrangements and discriminations that affect women (Young, 1990; Sherwin, 1992). It helps focus the meaning of care, relationships, and dependency (Tronto, 1993; Sherwin 1998), and of social and political justice (Young, 1990; Tronto, 1993). Feminist concepts of social justice, that include a positive obligation to alleviate unjust burdens of illness, poverty, and discrimination, for example, are particularly relevant to frail elders. It is prudent, according to feminist ethics, to realize in healthcare that we have a particular responsibility to disadvantaged or vulnerable groups (Young, 1990; McNally, 2003)/>
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