1. Refuse all further treatment and suggest that the patient find another general dentist

2. Refer the patient to an endodontist without further clinical contact. Give him some names and possibly help him to make an appointment

3. Prescribe Valium by phone and have the patient keep the original appointment

4. Refuse to prescribe Valium and rearrange the schedule to see the patient today

Identifying the Ethical Considerations

Beneficence and Nonmaleficence

In considering these choices in terms of the ethical considerations, several points can be made. First, some of the options do not directly benefit the patient. That is, they tend to violate the obligation of beneficence insofar as it requires benefit to the patient. The refusal of treatment in option 1 is an obvious example. Although the patient may follow the dentist’s advice and seek care elsewhere, he does so at more inconvenience to himself than is necessary. He might also delay contacting another dentist, which could be detrimental to him in the long run.

On the other hand, when option 1 is assessed in the light of the full implications of the principle of beneficence (taking into account benefits to parties other than the patient), the dentist should consider whether he can do more good for others by not accepting the patient. If, for example, he was caring for another emergency case at the time, he might conclude that beneficence required not taking this patient, at least at the moment. He might even consider beneficence to those who are not his patients. He might, for instance, be concerned about using his time for some other good purpose. Or he might be concerned about protecting his staff from harm.

Autonomy and Other Ethical Principles

Another major principle to consider is the principle of autonomy. While autonomy is often relevant in recognizing the right of the patient not to enter a professional-patient relationship, it also can imply the right of the dentist to be autonomous. This would have to be assessed in light of any promises made as well as the claims of justice that the patient might have. Any other principles including fidelity and justice as well as truth-telling (veracity) that may have bearing on the case need to be considered.

Referring the patient to an endodontist (option 2) can certainly be expected to benefit the patient, because of the special skills possessed by endodontists in the diagnosis of dental pain. This is especially true if the dentist expedites matters by offering him aid in identifying a practitioner and helping him to make contact. On the other hand, if Dr David’s original plan is sound, a referral may not prove to be necessary. Also, a referral will be more costly to the patient (or to the insurance company). If the referral to the endodontist at this time would be expected to further benefit the patient dentally, it would be more ethically acceptable. As it stands, Dr David’s motives, should he refer now, are more along the lines of dumping the patient. The ethics of any such plan would have to take into account the implications of other principles, including veracity. It would, for example, be dishonest to deceive the endodontist about the nature of the patient being referred.

Option 3, to prescribe Valium by phone and have the patient keep the original appointment, is controversial on two counts. First, it assumes there is some good reason why the patient cannot be seen on the day of the call, when, in fact, the only reason may be the dentist’s desire to avoid the patient. Second, if the dentist decides to prescribe Valium at this time, he deems the risks to be worth it. This belief cannot be based on clinical or scientific knowledge but rather is founded in a pre-established group of attitudes about drug addiction, its progress, and its treatment.

Decisions founded on such attitudes deserve ethical commentary. To not prescribe Valium could be said to be exercising nonmaleficence on the belief that, if Mr Worthy is an addict, additional Valium will add to his burden. On the other hand, prescribing Valium would have to be justified either by beneficence (on the belief that additional Valium will not be harmful even if Mr Worthy is an addict) or by autonomy (on the belief that Mr Worthy should have the right to be self-determining in the use of Valium). To select one course of action over the other is to endorse one set of beliefs and to reject the other.

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