Ethics in Pediatric Dentistry
Gunilla Klingberg, Ivar Espelid, and Johanna Norderyd
Ethical aspects in pediatric dentistry start right there in the clinic with the child patient we meet as dentists, the child patient that we should be able to communicate with, and to whom we are responsible for providing dental treatment and oral health based on best available scientific knowledge in combination with clinical understanding and experience, and taking the patient’s point of view into consideration. Thus, apart from the professional ethical codes we have to adhere to, ethics in the context of pediatric dentistry very much concerns how we look upon children as individuals and as patients. Through history society has viewed the child as an individual and as a person very differently. The status of the child in family, society, and health care institutions has varied a lot over the years, and there are still differences depending on culture and social structure. Our comprehension of the child today is very much influenced by our understanding of the child’s competencies in terms of psychological development, language, and communication skills (covered in Chapter 3) as well as new ways of reasoning about ethical and moral issues.
One important aspect in this is of course the Convention on the Rights of the Child , originating in 1989 and now ratified by the majority of nations worldwide. The Convention is founded on 54 articles, and articles 2, 3, 6, and 12 are usually identified as of major importance. The Convention applies to children and adolescents below the age of 18 and states that children actually have rights (defined in Article 1). This is essential and really the basis for understanding the Convention. Thus, the child has the right to life and development, should be listened to, be respected as a person and a human being, be protected against health hazards, discrimination, punishment etc. (Articles 2 and 6). In order to fulfill this, the child has the right to be involved in decisions affecting him or her and the child’s points of view should be respected, taking the child’s age and maturity into consideration (Article 12).
Article 3 declares one of the most important principles in the Convention, namely, the best interest of the child. The best interest of the child should always be a primary consideration in all situations and decisions where children are involved. In the dental health care situation this means that the organization and planning of dental care for children, including competency and number of staff, should be founded on the best interest of the child. So in order to fulfill this, we as dentists should have knowledge and competency regarding children and adolescents. We should know about physical as well as psychological development, be skilled in communication with children and their families, we should be orientated on how children spend their days, about school, culture, and social aspects related to the daily lives of children. This may sound pretentious, but is more a matter of having an authentic interest in children and adolescents.
The UN Convention on the Rights of the Child has impacted on the health care sector and how medical and dental care for children is organized and provided (e.g., [2,3]). Today, the child has a stronger position and her/his voice is not just listened to, but also often asked for when deciding about medical treatment and care [4,5].
Ethical considerations and analyses have become an important part of the clinical work of dentists, especially when working with patients who need extra attention in order to ensure that their viewpoints are recognized. There are several philosophical alignments that can be helpful. In this chapter we will focus on biomedical ethics. In the 1970s Thomas Beauchamp and James Childress published the textbook Principles of Biomedical Ethics, which has since appeared in several new editions ), which has been very influential in medical care [7–9]. The authors described different ethical principles of which four were considered central. These are often called the Georgetown mantra after the institution, Georgetown University in Washington DC. The four values are the principles of autonomy, non‐maleficence, beneficence, and justice.
According to the principle of autonomy the person should have the right to decide about matters of concern to her/him for as long as possible. But at the same time, the person should also respect the autonomy of others. In order to be able to make adequate decisions the person needs good, thorough, and understandable information from the dentist about the actual diagnosis and possible treatment. This is a prerequisite for the person’s/patient’s decision‐making. Corollary, the person/patient always has the right to reject a treatment provided she/he is competent to decide about this, but cannot demand a certain treatment as all treatment should be provided according to the principle of lege artis, i.e., according to the law of medical art, based on scientific evidence and performed the correct way. The treatment is delivered by someone, and if that professional, e.g., the dentist, does not agree with a treatment demanded by a patient he/she is not obliged to carry it out.
Non‐maleficence is an old and well‐recognized principle that goes back as far as to Hippocratic Oath, that we should not harm a patient. At first glance, this might be considered easy, but it is not always so. For example, some dental treatments are painful, and from the perspective of non‐maleficence they might therefore be on the borderline according to this principle. Still they are carried out, just to mention a few potentially painful treatment situations: the risk of procedural pain when having an injection of local analgesia, or pocket probing. This is not necessarily in contradiction to the principle provided that the patient (or her/his advocate) has supported it by giving informed consent and that the treatment is good and promotes health. For obvious reasons it is, however, important that the dentist always tries to minimize the risk of pain and discomfort. Local analgesics, general analgesics, sedation and most of all an empathic attitude in meeting and caring for patients are essential in this context. It is never right to carry out a treatment that causes pain and discomfort without trying to minimize the harm for the patient unless the situation is more or less life threatening, which is rarely the case in dentistry.
The principle of beneficence has a very strong position in all health care. It is in the interest and good of the patient as well as society, and concerns the idea of ensuring that we deliver effective and good treatment. Dentistry is developing fast, and new methods and materials are frequently launched onto the market, but very few of them are fully evaluated from a scientific point of view. Again the idea of working according to lege artis is present here. Knowledge about how to evaluate and use scientific results in a systematic way, such as evidence‐based methodology for evaluation of dental treatment, is one way of ensuring that we work according to the principle of beneficence. We have a responsibility as professionals to be updated on dentistry, but also to be critical of new methods until we are convinced that they are good.
The principle of justice states that every person should have the same and equal right to access the same kind of dental care and treatment regardless of age, gender, social position, education, ethnic background, religion, and so on. For obvious reasons this principle may be hard to abide by in societies where there is a shortage of dental care as well as of finances. Still, society has a responsibility to strive for an equal possibility to achieve good oral health for the whole population. Especially important for society is to ensure that there are facilities for delivering dental care to vulnerable groups of patients, e.g., children, elderly, and patients with disabilities, or those who are medically compromised.
Informed consent—from the perspective of pediatric dentistry
Historically, culture has allowed medical professionals such as doctors and dentists to have absolute authority in the health care situation. They have seldom been questioned or criticized; their word and opinion have been readily accepted by patients as well as by society. This paternalistic apperception that “the doctor knows what is best”‘ is now being questioned and replaced by the idea of the patient having much more to say about her/his own treatment. Today’s patient has a strong position in all health care. Still, it is important to keep in mind that there are cultural differences between countries, and also between different parts of a population owing to age, religion, ethnicity, and so on. Treating children and adolescents is different from treating adults . There is a triangle of people involved in the dental treatment—first of all, the young patient, then also the parent, and the dentist (see also Chapter 6).
An adult, competent person is usually able to decide for her/himself. The respect for a person’s autonomy usually has priority over the principle of beneficence when treating adults. Children, however, are not free‐standing agents; they belong to a social unit in which parents usually make the final decisions. Often both parents and dentists are willing to subordinate respect for the child’s autonomy to the value of the child’s benefit. Thus, if a certain treatment is considered essential and beneficial for the child, parents and dentists may see this as the most important aspect when deciding about treatment. The child’s autonomy is often looked upon and weighed differently than that of an adult patient. That is why communication is important. If the dentist is able to describe to the child what needs to be done, why and how, the child will be able to take part in the decision‐making and the dentist can in fact receive an informed consent from the young patient. But the information must be age appropriate and the child must feel safe and comfortable in the situation.
Integrity and autonomy
Integrity can be described as the right of a person to have an area protected against intrusion, i.e., a private sphere or space where human dignity is central. Every person or human being has integrity (or dignity), as it is present right from birth, but it can be transgressed by others. Other people can step into this private sphere without respect for the person, thereby violating integrity. An example from the dental care situation is when you have a child patient and you do not meet and confirm that child as an important person. Maybe you simply forget the child because of encountering a parent who demands attention. This is easily done if you are not observant of your own behavior and fail to remember that the child is your patient and therefore should be your main concern. It is sometimes a delicate balancing act to clarify for the parent that the child is the patient and thus the individual to acknowledge and communicate with in order to respect integrity, while at the same time maintaining a respectful attitude towards the parent.
By autonomy we mean the right of a person to decide about her/himself, to be a competent person. Autonomy in the dental care situation allows the patient to decide if she/he wants to go through with a treatment or not. Autonomy also serves as a shield protecting the person’s integrity. In contrast to integrity, autonomy is not always present; it has to be won, and it can be lost (Figure 27.1). The newborn child cannot exercise autonomy; instead, autonomy is gradually gained as the child develops and grows older. There is a need for a certain level of reasoning in order to uphold autonomy. The very young child is not yet capable of this, nor is the old or very ill or dying person. Moreover, autonomy can be temporarily lost, e.g., when a person is under general anesthesia, and it can be reduced or undermined by illness, disability and so on. Autonomy can also be violated by others. For example, if we carry out dental treatment that the patient has not given consent to or agreed to, we as dental health care professionals are trespassing and violating the autonomy of this individual.
So how can we then assure that we do not trespass when we have a young child in the dental chair? We have to make sure that there is another person present functioning as advocate for the child . Thus, a person who substitutes autonomy and provides proxy consent for the child should be identified. This person is often the parent or legal caretaker. Some countries have regulated this in legislation. But as dentists working with children we also have an obligation to not take for granted that the parent is automatically the best proxy for the child. The person substituting autonomy must take the full perspective of the child when giving consent and deciding about treatment. This includes asking her/himself what the child would think about this if he or she were able to fully understand. Most parents are very good at this, but there can be conflicts of interests. For example, a parent might prefer a treatment that is quicker even though it is not in the best interest of the child. Therefore, the dentist should not only be aware of this, but also be prepared to act as advocate for the child (or other patients with decreased autonomy) in decisions about treatment. The treatment, as well as the modes of treatment, should be in the best interest of the child.
Deciding on treatment
Sometimes there is conflict between different ethical principles, for example the non‐cooperative child that has a cavity requiring filling therapy but who is not willing to go through with treatment. Here is a potential conflict between autonomy and beneficence. When there is conflict between different principles, a rule of thumb often advocated is to settle for the treatment that is in the interest of the majority of principles and individuals involved. In many cases an ethical analysis will reveal that much treatment actually can be postponed. There is seldom, with a few exceptions, a need for immediate treatment and very rarely conditions that are life threatening in dental care . Instead, it is important that the treatment is beneficial to the child in a long‐term perspective, which is why it may often be wise to invest time in the patient by stepwise introduction to the treatment, or desensitization if the child is very anxious. If this is an alternative the dentist should of course make a decision taking into consideration the specific odontological diagnosis, the treatment needs, and consequences of postponing or refraining from treatment. If there is a situation where the dentist has to choose between two different treatment alternatives, the alternative that provides positive long‐term effects for the child should be given priority before an alternative that may be efficient in a shorter perspective, but counterproductive in a longer perspective. In most cases it is not necessary to rush to treatment. Instead, pausing, thinking it over, and analyzing possible ways of treatment is feasible and may in fact lead to a better future outcome.
It is hardly acceptable to push treatment in a direction where restraint is used just in order to carry out a simple treatment such as fissure sealant therapy, while an avulsed permanent central incisor in a young child could be a rather different situation. In the latter case an immediate replantation may be in the best interest of the child as the long‐term prognosis is correlated to more direct action. In this case it may, therefore, be more acceptable from an ethical point of view if treatment is carried out even though the child is protesting. The dentist should of course do everything to make it easier for the child to cope with the treatment. This should include prevention of pain and possibly also using sedation.
There are many clinical situations where ethical aspects could and should be discussed. Ethical discussions and analyses can constitute a normal and vital part of clinical conferences where clinical cases are discussed in order to improve diagnosis and decision‐making in relation to therapy. There are different tools that can be used in this process [12–14].
It is probably easiest to illustrate this using a clinical case, for example, the one in Box 27.1. The analysis weighs the perspectives of the different parties involved—John, John’s mother, the dentist, and society—on different ethical principles. Figure 27.2 gives an outline for this process. In this case the following principles should be discussed: respect for autonomy, beneficence–maleficence, and justice. To start with respect of autonomy—John’s wish and well‐being should be respected as far as possible. His experience of the dental treatment will probably affect future dental visits. If treatment is carried out against his will, this could give rise to dental anxiety and dental behavior management problems in the future (beneficence–maleficence). Mother’s wish is understandable, and normally she should stand in for her son’s autonomy. But in this situation it can be questioned if she is really reasoning and acting in the best interest of her son. Maybe her own stress is the ruling factor. From the dentist’s perspective a tooth extraction carried out against the will of a patient, and probably under conditions where pain control can be difficult, is far from optimal or desirable. Society would prefer a treatment that will cost as little as possible both financially and in terms of loss of health or well‐being.