Ethical Principles

Ethical principles provide a framework for judgment and decision making. The American Dental Association’s Principles of Ethics and Code of Conduct, and other professional codes, outline 5 principles and offer commentary ( https://www.ada.org/en/about-the-ada/principles-of-ethics-code-of-professional-conduct ).

A foundational principle in ethics is nonmaleficence. This principle is commonly known as “Do no harm” and means that the provider’s first obligation is to the patient. It is associated with preventing and removing harm. A dental office shows this principle in all activities, ranging from disinfection and sterilization of operatories and equipment, to treatment and patient education.

Beneficence is an obligation to promote each patient’s welfare and best interests. Beneficence requires providers to deliver services to their patients and the public at large. A patient’s needs, desires, and values are taken into consideration in the dental office setting.

Autonomy is based on respect for an individual. The principle allows individuals to be self-governing and self-directing in their decision making. Providing accurate information related to treatment and treatment outcomes shows a respect for the patient’s autonomy in determining whether to accept or decline a treatment plan.

Justice is fairness, an obligation to treat people equitably. This principle applies to patients, colleagues, and society. Dental services should be provided without prejudice.

Veracity is truthfulness and requires a duty to communicate honestly and clearly. It supports a relationship of trust between the provider and the patient critical to the relationship.

Additional ethical principles include confidentiality and fidelity. Confidentiality is an obligation that limits access to information that is provided by a patient to a provider. Fidelity recognizes the special relationship that develops between patients and providers. It may be viewed as providing quality competent care to patients as part of the providers’ professional responsibility.

Dental providers are credentialed and licensed to provide care to patients. In addition to adhering to the ethical principles, Integral to their professional standing within their community and among their peers is an expectation that interactions with patients, parents and guardians, and peers will model the following characteristics:

Legal Principles

An understanding of legal principles guides providers in their day-to-day interactions with patients. Dentists can be sued for both criminal and civil violations. Dentists are often concerned about allegations of negligence. Dentists can be guilty of criminal offenses related to sexual misconduct, drug diversion, and fraud. State dental practice acts and legislation may hold dental providers accountable for other actions, including reporting child abuse and child neglect and human trafficking.

Civil Law

There are 2 types of civil law. Tort law is interfering with an individuals’ ability to enjoy their persons, privacy, or property. There are 3 types of tort classifications:

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  Intentional torts occur when an individual intentionally commits a wrongful act causing harm to another individual. There is a requirement to show that the person committing the tort did so on purpose.

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  Unintentional torts occur when there is unintentional harm to a person and a failure to exercise a reasonable standard of care, such as in dental negligence. Four elements are necessary to prove an unintentional tort:

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    A duty is owed to the patient

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    A breach of the duty occurs

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    Patient suffers damages

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    The resulting harm is caused by the breach (causation)

From a legal perspective, third-party payers have a significant role in dental care quality assurance. From the perspective of proper use, ensuring quality outcomes, and documentation of medical necessity, third-party payers are increasingly involved in the review of care. With 37,581,693 minors enrolled in the Children’s Health Insurance Program or children enrolled in the Medicaid program in the 50 states, the single most prominent influencer of allegations of improper care stems from utilization reviews.

Third-party payers are incentivized and contractually required to implement quality improvement and utilization review programs. As a result, audits of dental records can result in allegations of improper treatment and overtreatment. These audits are defensible with proper documentation and justification of medical necessity. Absent appropriate documentation, the provider is subject to demands for repayment for unnecessary care, allegations of malpractice, and potential state board action. Third-party payers can extrapolate the value of losses based on a sampling of a subset of patient records. Based on the extrapolation, providers may find themselves responsible for hundreds of thousands of dollars of repayment.

In general, the period for the statute of limitations for malpractice on a minor allows for a claim to be filed for up to 3 years from the date of the alleged injury, or, if the alleged injury is concealed, 3 years from the discovery of the injury, or 6 months from the child’s 18th birthday, whichever is longer. There are minor variations in the statute of limitations laws between the various states.

Regarding malpractice claims, the highest risk for settlement relates to anesthesia overdosing, nerve trauma during surgical procedures, malocclusion and subsequent temporomandibular joint dysfunction, and lacerations to the soft tissue. Emerging areas for liability include the need for practitioners to carefully understand and assess the airway and the possible impact of malocclusion on adult obstructive airway apnea, because, left untreated, some malocclusions could create comorbidities with sleep apnea in adults.

Contract law is the second area of civil law. A contract is an agreement between 2 or more consenting and competent parties to do or not to do something for which there is an exchange value, such as payment for services. Dentists have contractual relationships with their patients based on either a written agreement, such as a treatment plan, or the patient’s actions of seeking care and the dentist providing the care. The contractual relationship holds the dentist and patient to specific obligations, including delivering competent and timely care by licensed professionals, using acceptable dental materials and techniques, and remaining current and up to date. Because government-sponsored insurance plans cover so many children, it is critical to note that the most important and most significant contract related to the provision of care is the provider agreement that dentists enter into as a part of their insurance participation. These participation agreements set parameters for expectations related to the predictability of the outcomes of care and the need to justify the performance of only medically necessary care. These contracts also prescribe the payment schedule for each procedure and the reasons for payment ineligibility.

Informed Consent and Informed Refusal

To successfully meet the standard of care, a dental provider must fulfill the duties associated with the action performed. A duty is a legal obligation. Duty requires that a provider use care toward others that would protect anyone from unnecessary harm. Dentists, by the nature of their education and licensure, have a variety of duties. Patient care includes assessment, treatment planning, treatment, evaluation of outcomes, and maintenance of oral health.

Informed consent is the patient’s right to understand the recommended procedures, risks, and alternatives. The ADA Principles of Ethics and Code of Professional Conduct section 1.A, entitled Patient Involvement, clearly states that the dentist should inform the patient of the proposed treatment and any reasonable alternatives that allow the patient to become involved in treatment decisions. It is the duty of the dentist to obtain consent. Informed consent, whether sought from an adult or adolescent that has the right to give consent, includes specific elements to comply with the obligation that it must:

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  Include description of the procedure in simple terms

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  Include disclosure of the benefits/adverse risks of the proposed treatment specific to that procedure

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  Include evidence-based alternative treatments

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  Include disclosure of benefits/adverse risks to the proposed treatment

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  Be freely given

A dentist seeking informed consent may view the parent or legal guardian as the only individual who can provide consent for a patient younger than 18 years. This view is a strict interpretation of the laws and constructs of informed consent; however, depending on the state and the situation, in practice the adolescent can be deemed able to render consent.

Many pediatric experts think that, for children as young as age 7 years, effort should be made to include the child in the decision-making process. “A developmental approach to assent anticipates different levels of understanding from children as they age. Providing disclosure of appropriate diagnostic and treatment information and allowing choices about aspects of care, when possible, should be a consistent part of the care plan for children.”

Dental providers must show that the care provided and that the options provided for informed consent meet the standard of care, which requires providers to deliver care options consistent with what a reasonably prudent dentist would provide in the same or similar circumstances. Depending on the state, the standard for informed consent could be different. The breadth and depth of the information provided should be consistent with what a reasonably similarly situated patient and reasonably similarly situated prudent practitioner would think necessary to make an appropriate decision. Dentist who do not meet the standard of care may be guilty of negligence. The information should be presented in a manner the patient and responsible adult can understand. Documentation of the informed consent process should be in writing. It is advised that the responsible adult signs the documentation of the informed consent process as evidence to document the process. The risks of nontreatment must be carefully documented and explained in a manner consistent with the cognitive level of the patient and the responsible adult. Requiring the responsible adult to sign a statement acknowledging informed refusal of treatment is recommended.

It should be noted that laws vary related to the age of consent for minors, and the rules governing consent for the treatment of minors are determined by state law. Most states currently have laws that give minors the right to consent to treatment in specific situations. Depending on the state, minors may be allowed to legally consent to treatment of sexually transmitted diseases, birth control, pregnancy, mental health, and substance abuse. In addition, these states often protect as confidential information related to treatment of sexually transmitted diseases, birth control, pregnancy, mental health, and substance abuse. Practitioners should be familiar with the laws governing consent within their jurisdictions. Whenever an adolescent is accompanied by an individual who is not the parent or legal guardian, a provider should be cautious in allowing that individual (eg, a grandparent) to give consent without appropriate documentation.

Based on the circumstances and the urgency of the situation, exceptions to the laws regarding consent allow for emergency care without specific parental consent. Different situations may also allow for the minor to legally consent for their own medical decisions. This provision may include court-ordered emancipation for a child less than 18 years old who lives without parental support and makes day-to-day decisions. In this case, the emancipated minor holds the same legal rights as an adult. Situational emancipation may result from marriage, being a parent, and being a member of the military, and such individuals can consent to their care. Some states use the term emancipated minor.

Because of their ability to drive or use public transportation, adolescents may arrive for a dental appointment without a parent or guardian. A dentist is obligated to get consent from the parent/guardian for dental procedures. This consent can be accomplished via a phone call or Zoom meeting if available. A witness, such as a dental assistant, should be available to hear the discussion and confirmation of consent.

The office should develop clear policy and educate patients about policy and procedures for the care of minors, including the parent/guardian obligation to be present in the office. For example, a policy should clearly state that, for patients between the ages of 12 and 17 years, a parent cannot drop the child off and leave the office, or the parent/legal guardian, if allowed to leave the office, must (1) be available by phone, (2) sign all required documentation, (3) allow only routine treatment.

Informed refusal is a decision by a patient or the parent/legal guardian to decline treatment. The process of informed refusal parallels informed consent, with similar elements required. It is advisable to document refusal of treatment, referral, preventive measures, restorations, and other suggestions made by the provider.

Decision Making and Adolescent Patients

Decision making concerning a patient’s care is a responsibility shared by a dentist and the parent or legal guardian. The objective is the best interest of the patient. Dentists should be aware of child-rearing practices that religious, social, and cultural differences may influence. There should also be an awareness that parents may breach their obligations, resulting in child abuse and neglect.

As a minor, an adolescent may not have achieved emancipated status. Decision making about care should include the assent of the patient to the greatest extent possible with the participation of the parents/legal guardian and providers. Consent is given by individuals who have reached the legal age, whereas assent is the agreement of someone not able to give legal consent. Dentists are advised to give serious consideration to each patient’s developing capacities during adolescence to participate in decision making, including rationality and autonomy. Providers may not be legally allowed to solicit consent from a minor; however, involving the minor in the discussion about care fosters a stronger provider-patient relationship. Assent can be determined through verbal and nonverbal conduct. When working with adolescents, assent should include at least the following elements:

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  Helping the patient achieve a developmentally appropriate awareness of the nature of the condition

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  Telling the patient what to expect with the treatment

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  Making a clinical assessment of the patient’s understanding of the situation and the factors influencing how the patient is responding

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  Soliciting an expression of the patient’s willingness to accept the proposed care

The Health Insurance Portability and Accountability Act

A parent or legal guardian or other person authorized by a state has the right to an adolescent’s medical information. However, if the minor has the right to health care under the state or other law or decision, the minor has an exclusive right to control access to health care information related to the care. A parent can also agree to a confidential agreement between a provider and a minor and then the parent has no right to the information. This situation may frequently occur between a health care provider (eg, physician) and minor. A provider may refuse to provide a parent/legal guardian with information in situations of domestic violence, abuse, or neglect or where the minor could be endangered. However, even in these exceptional situations, the parent may have access to the medical records of the minor related to this treatment when state or other applicable law requires or permits such parental access. If the state or other applicable law is silent on a parent’s right of access in these cases, the licensed health care provider may exercise professional judgment to the extent allowed by law to grant or deny parental access to the minor’s medical information.

The Privacy Rule generally allows parents to have access to the medical records about their children as their minor children’s representatives when such access is not inconsistent with state or other law. There are 3 situations in which the parent would not be the minor’s representative under the Privacy Rule. These exceptions are:

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  When the minor is the one who consents to care and the consent of the parent is not required under state or other applicable law

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  When the minor obtains care at the direction of a court or a person appointed by the court

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  When, and to the extent that, the parent agrees that the minor and the health care provider may have a confidential relationship

Dental practitioners should also be aware that the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule does not cover any health information provided as part of an educational health screening for athletic participation or preenrollment screening. Rules governing access to medical records for adolescents and the protections against disclosure for pregnancy status and sexually transmitted diseases are not afforded the same protection under the Family Educational Rights and Privacy Act (FERPA), a federal law enacted in 1974 that protects the privacy of student education records.

Risky Behaviors

Adolescence is associated with an increased incidence of risk-taking behaviors. Dentists should be aware of the risk-taking behaviors in adolescent patients and monitor current trends or fads. A careful examination of the patient, including a dental and health history, may assist the dentist in identifying such behaviors. The patient may not feel comfortable admitting any of the following behaviors. However, signs and symptoms of such behaviors may be evident to the dentist or a staff member; for example, staining, broken teeth, sudden increase in caries rates, and/or sexually transmitted infections. The dental team should discuss how best to address the issues with the patient and/or the parent and legal guardian. Current trends include:

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  Tobacco use

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  Alcohol and binge drinking

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  Unhealthy dietary practices

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  Adolescent sexual activity

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  Dating violence

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  Substance abuse

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  Mental health issues

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  Oral piercing

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  Weapons possession

Dental patients often develop a relationship of trust with members of the dental team because of an established long-term relationship. During treatment, certain disclosures may reveal risky behaviors on the part of the adolescent patient. The dental team must be prepared to address and respond to any of these situations.

Bullying and Cyberbullying

There has been increased attention to bullying and cyberbullying in the media. The World Health Organization (WHO) and the United Nations recognize bullying as a global health challenge. Bullying is often associated with repeated, intentional, and targeted behavior seeking to intimidate or marginalize someone. Bullying is common and widespread, with the National Center for Educational Statistics reporting that 1 out of 5 students report being bullied. Cyberbullying is using a digital device to send, post, or share negative, mean, or false content, with the same intent to intimidate or marginalize another.

Dental practices often have long-standing relationships with patients and can often detect signs of emotional abuse and neglect. Although the strength of the association is in debate, children with observable dental problems and malocclusions have an increased incidence of bullying and emotional abuse. Whether it is from within the child’s home environment or from the child’s social circle or at school, dental practitioners have an ethical obligation to be alert to the signs and symptoms of emotional abuse associated with bullying.

The common signs of emotional abuse include a lack of interest in conversation, weight loss, unwillingness to participate in activities, and poor academic performance. It is important ethically to educate members of the dental team to recognize the signs and symptoms of bullying.

Pregnant Adolescent Patients

Patients may disclose to a dental provider their pregnancies. Dentists may be presented with an ethical dilemma when a patient requests that the parent or guardian not be informed. The dentist needs to weigh the issues and decide about the next steps. From an ethical and legal viewpoint, the patient and their fetus need to be protected and cared for, thus informing a parent or guardian may be the appropriate step. However, providers should talk with the patient to make sure that the patient is not put in harm’s way because of the disclosure, and, instead of informing the parent, protective child services may need to be contacted. The situations that could trigger contacting an external agency include the pregnancy resulting from a parent or someone in the household sexually abusing the patient, or patients feeling that they will be in danger if the pregnancy is reported. It is the obligation of the provider to get information about the patient and the personal circumstances before deciding whether to inform the parent/legal guardian or choose another option.

Tooth Whitening

Adolescent patients and their parents may request specific procedures that the dental provider may or may not be comfortable doing. Adolescent patients often have an increased self-awareness of their appearance and often express interest in cosmetic procedures. Professional associations offer guidance to providers. The American Academy of Pediatric Dentistry discourages full-arch cosmetic bleaching for child and adolescent patients in the mixed dentition and primary dentition. ( https://www.aapd.org/globalassets/media/publications/archives/lee-27-5.pdf ).

Current Trends and Issues

To satisfy dental providers’ legal and ethical obligations, dentists need to be cognizant of current trends and issues as health care providers.

Child abuse and neglect

There is an ethical and legal obligation to report suspected abuse and neglect. Dental providers should use their training in identifying mistreatment and be familiar with the agencies responsible for child protection and the process for reporting.

Human trafficking

Human trafficking is a criminal human rights violation and significant health issue. Many jurisdictions require that dental professionals report suspected human trafficking. Trafficking frequently occurs in women, children, and adolescents. Education about the signs of trafficking and protocol for reporting are important to know.

Responsible opioid prescribing

Dental practitioners have a legal and ethical duty to manage patient discomfort responsibly. Increasing evidence suggests that dental prescribing of opioids contributes to addiction and abuse behaviors. In addition, the Drug Enforcement Agency has enhanced its enforcement efforts against dentists who are prescribing without documented medical necessity. Many states have laws and regulations regarding the prescribing of controlled substances and specific registration requirements.

Gender Identity/Transitioning Patients

A 2017 University of California, Los Angeles, study estimated that 0.7% of teenagers aged 13–17 years identify as transgender. That translates to 150,000 teenagers nationally. A subsequent Minnesota study of ninth and eleventh graders found that 2.7% identified as transgender or gender nonconforming. The Centers for Disease Control and Prevention (CDC) reports that nearly 2% of high school students identify as transgender.

Regardless of the exact number, dentists need to be aware and responsive to the needs and issues associated with gender identity and gender nonconformity. Patients who are expressing transgender identities and gender nonconformity are more likely to have depression and engage in other risky behaviors.

Transgender teenagers also show oral sequelae, including oral manifestations from pharmaceutical drugs and poor dietary and eating habits. Dental teams have an ethical responsibility to adequately educate themselves on the needs of transgender adolescents and prepare themselves to accommodate and support the patients’ emotional and psychological expression of their identities.