Ethical problems in dentistry, like ethical problems in general, can sometimes be approached by looking at which general principles are at stake. Two of the most obvious are that actions tend to be right insofar as they produce good results and wrong insofar as they produce bad or harmful ones. Sometimes these two notions are referred to by their more technical names—the principles of beneficence and nonmaleficence, or the principles of doing good and not doing bad.
In some people’s ethics these are the only principles that count, while in others’ there are additional features that lead to calling an action morally right or wrong. In later chapters in Part II of this volume we look at some of these other principles, including the principles of autonomy, truth-telling, fidelity, and justice. These latter principles hold that independent of whether one’s actions result in good or bad, they can be judged wrong morally if they involve lack of respect for the autonomy of others, telling of lies, breaking of promises, or unfair allocations of benefits and harms.
Even if one focuses only on questions of doing good and avoiding harm, however, matters of moral controversy can arise. The cases in this chapter were chosen because they pose questions about what is the morally right thing for a dentist to do based solely on judgments about doing good and avoiding harm.
Traditional ethics has held that the dentist should do what will benefit the patient and protect the patient from harm. This idea can be traced all the way back to the Hippocratic Oath, in which the health professional pledges to apply measures “for the benefit of the sick according to my ability and judgment. I will keep them from harm and injustice.”1
In a similar vein, the American Dental Association’s (ADA’s) Principles of Ethics and Code of Professional Conduct holds that “professionals have a duty to act for the benefit of others. Under this principle, the dentist’s primary obligation is service to the patient and the public-at-large. The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires, and values of the patient.”2 Included in virtually any professional ethic is the idea that doing good counts morally in favor of an intervention and doing harm counts against it.
This might seem so obvious that it is nothing more than a moral platitude. Still, there is room for dispute over how the doing of good and harm relates to morality in dental practices. First, it is controversial how benefits relate to harms. For instance, is it always acceptable to do harm to a patient provided it is accompanied by a greater amount of benefit? Second, there are controversies in deciding just what counts as a benefit in dentistry. The patient’s view may be quite different from that of the dentist. Third, even if we know what counts as a dental good or harm, we may have ethical problems in relating these dental consequences to other (nondental) benefits and harms. A patient may purposely reject an offered dental benefit in order to invest time or money in something else he or she desires. Fourth, controversies sometimes arise over the moral duty of a dentist regarding benefits and harms for nonpatients, either former patients or those who have never been patients. Finally, there are many instances in which the interests of patients conflict with others who are not patients. This includes the interests of the dentist as well as the interests of the society in general. In this chapter we look at moral problems involved in relating benefits and harms, in the principles of beneficence and nonmaleficence.
One classical problem in health professional ethics is how benefits relate to harms.
While the Hippocratic tradition simply asks the health professional to do good for the patient and protect the patient from harm, other moral codes in health care give a special priority to avoiding harms. The slogan primum non nocere (first of all, do no harm) is one of the most widely used in health care ethics.3,4 It is often interpreted to mean that avoiding harm has a special moral priority over doing good. The dentist, according to this view, should only strive to do good for the patient when he or she has first of all made sure no harm would come to the patient.
On the other hand, many individuals, drawing on the original form of the Hippocratic tradition, treat benefits and harms as being on a par. They see them as being equally weighty, so that the harms can simply be subtracted from the benefits when deciding which action does the most net good. They would consider the possible good from each course (taking into account both the amount and probability of good) and subtract the possible harm. A closely related way of reasoning about benefits and harms is to calculate the ratio of benefits to harms. This is often done formally in what is called a benefit-cost or benefit-harm analysis, but it is done intuitively by dentists constantly during the course of dental practice.
One major problem with this reasoning is that benefits and harms are often notoriously hard to quantify. We surely are not concerned only about monetary costs. We need to take into account pain and suffering, as well as the satisfaction of a well-functioning dentition, esthetic pleasure resulting from attractive teeth, and so forth. Surely, estimates of benefit and harm are only approximations, but such estimates are made constantly in all decisions in life, including complex decisions in health care.
The first problem we encounter is what we should do with these estimates of benefit and harms after we have made them. Do we simply subtract the harms from the benefits for each possible course of action, do we calculate the ratios, or do we strive first of all to make sure that as dentists we do not harm our patients while trying to help them?
Dr Joanne Heller, a pediatric dentist, had been treating Sylvia Maldin for several months, and the treatment was now finished. Sylvia was a 12-year-old girl with extensive dental caries who had been referred by a general practitioner because she had physically refused all treatment. Dr Heller had been able to work with her effectively, partly through conventional communication skills, which led to an increase in Sylvia’s trust, and partly with some pharmacological help.
Dr Heller had been using combinations of Demerol and Atarax. Her strategy, over time, was to gradually reduce the dosage in a weaning process. She considered her experience with Sylvia to be a good one. She liked Sylvia, and she knew that she had helped Sylvia to overcome some significant problems in coping with dental care, which hopefully would carry her through a lifetime.
As Sylvia was getting ready to leave after her last visit, she thanked Dr Heller for what she had done, especially for showing her how helpful drugs could be in overcoming difficult situations. Sylvia thought, for example, that drugs could help reduce her anxiety in confronting new situations, meeting new people, or coping with the stress of taking examinations. She asked if Dr Heller could prescribe some more drugs for her that she could use in those situations.
Dr Heller tried to impress upon Sylvia that she could not legally or ethically do what Sylvia asked and that to do so could harm her. Sylvia expressed her disappointment and said that she regretted having trusted Dr Heller as a friend. But in the end, Sylvia said, it probably did not matter; she thought she could get what she needed in the schoolyard.
Dr Heller was shocked and appalled by Sylvia’s comments. It had never entered her mind that she was in any way harming her patient. Now her certainty that Sylvia had benefited from the treatment wavered.
When Dr Heller is deciding between possible treatment plans, she will list, at least mentally, the potential benefits and harms of alternative courses of action and the probabilities of their occurrence. A drawback to this method is that one must be sure to identify all of the possible benefits and harms. In this case Dr Heller did not anticipate the subtle but important risk that she could be teaching her patient to be a drug abuser.
The first question the case raises is whether Dr Heller was at fault for failing to anticipate this risk. Should she have been on the alert based on the fact that she knew Sylvia was an unusually difficult patient (so difficult that the general practitioner referred her to a specialist)? Of course, if she should not be expected to take into account the risk, it is hard to hold her at fault.
What is the extent of the dentist’s obligation to anticipate such risks?
At this point it is fair to say that most pediatric dentists would be reluctant to use sedation in the way that Dr Heller did. Sedation over multiple appointments is usually reserved for children in the 2- to 5-year-old bracket. Older children such as Sylvia, who are difficult to manage clinically, often represent more complex emotional problems that would best be handled under general anesthesia or intravenous or other forms of deep sedation, in which the goal is to complete all necessary treatment in as few visits as possible. Nevertheless, there are risks from general anesthesia and other forms of deep sedation. Depending on the evaluation of the alternative risks and benefits, Sylvia, her parents, and Dr Heller may be within reason in choosing the option that they did as long as the risk of future abuse was so remote that it was appropriately ignored.
Assuming that she did anticipate the risk and could attach some probability to it, another kind of ethical question arises. Should Dr Heller simply calculate the potential benefits and the potential harms and choose the course of action that is expected to produce the greatest possible net benefit, or is there some other way that she should reason them through?
In some interpretations of health care ethics, the practitioner takes as his or her motto, “First of all, do no harm.” Avoiding harm done by one’s own hand is morally considered the first priority. Even if as much or more good were done, according to this view, it would be wrong to do the harm. For example, in medicine it seems obviously wrong to kill one person even if in doing so we could obtain several organs for transplant that would save a number of lives. We do not simply calculate the number of lives saved and subtract the one life taken to conclude that the killing would be justified. Some people have argued that the reason it seems obviously wrong to kill one person to save many is that actively doing harm is morally worse than, or more significant than, doing good.
In this case, if Dr Heller should have anticipated the possibility that she would be encouraging her young patient to become a drug abuser, should that be seen as something the clinician should avoid at all costs, or should she try to calculate the amount of harm and compare that harm to the potential benefits of using the drugs?
In calculating the expected benefits and harms, we would normally estimate their seriousness and multiply by the probability (at least as a mental estimate). For Dr Heller one such calculation might be that the important benefit of Sylvia’s long-term willingness to accept regular dental care could have a 70% chance for success. On the other hand, one might estimate that the extremely serious harm of encouraging drug abuse might be as much as 5%. Although the estimates are subjective, the process can be very helpful in focusing on the implications of harm.
If we give special priority to avoiding harm to patients, what should we make of the fact that virtually all dental interventions risk at least modest, short-term harm? Even modern dentistry hurts sometimes. Would an absolute priority for not harming the patient make even a needle stick immoral? After all, that needle is, for many patients, the most severe mental and physical pain that they experience in the dentist’s chair. Surely, we do not want to give such high priority to avoiding active harm of the patient that the dentist is totally immobilized.
There is one other concern that needs to be addressed. What, if any, are Dr Heller’s obligations to Sylvia and her parents once she recovers from the shock of Sylvia’s departing comments? Is she required to take steps that might help circumvent Sylvia’s inclination to use drugs? Should Sylvia’s parents be called in for a conference, or should Dr Heller respect Sylvia’s confidentiality? If Dr Heller does decide to call them in, should she tell Sylvia beforehand of her intentions? How should she describe what has happened, and what should she recommend the parents consider doing? How should she portray her own role in precipitating what happened? These questions also arise in chapter 7 when confidentiality is the topic.
Mr Carl Bengstom, age 38, was referred to Dr Jose Gutierrez, an oral and maxillofacial surgeon at a large research-oriented hospital on the West Coast. Mr Bengstom suffered from polydermal myositis, a connective tissue disorder with severe systemic effects. Therapy for polydermal myositis is largely palliative and, for Mr Bengstom, had included prednisone for many years. More recently he also took methotrexate on a monthly basis. Of importance in this case was delayed healing, especially in his lower extremities. He had a tendency to get ulcers in this area, and they took an exceedingly long time to heal.
Mr Bengstom’s life was very difficult, and he was miserable most of the time. One of his main problems was his appearance. His face was severely distorted because of the overgrowth of his maxilla. The distorted growth involved significant asymmetry and a very long maxilla from a vertical perspective, which resulted in an extremely large overbite. In addition, there was essentially no masticatory function; the only contact between his maxillary and mandibular teeth was a single point on one cusp of the maxillary and mandibular second molars.
Adding to Mr Bengstom’s problems was the extensive destructive resorption of the condylar heads of the mandible as seen radiographically. There was only 1 mm of bone between the middle cranial fossa and what remained of the condyles. This finding increased the risk of any surgery in the condylar area. There were two broad choices for Mr Bengstom: have nothing done or undergo extensive maxillofacial reconstruction.
Dr Gutierrez thought about what he should tell Mr Bengstom about his options for treatment. Certainly one possibility was not to do any surgery at all. The risks of failure of the surgery were high, especially because of Mr Bengstom’s healing difficulties. Furthermore, if postoperative infection were to occur, it could be life-threatening. The possibilities of relapse also had to be considered in view of the nature of the disease. Another problem was whether to insert prosthetic replacements for the diseased condyles. Two surgeons he consulted favored this approach. However, Dr Gutierrez decided that if he undertook the case he would not use prosthetic condyles because he thought it would be unwise to employ a foreign object in a patient with healing problems.
Despite these substantial risks, if surgery were done, there was also the possibility of a major improvement in appearance and function. Dr Gutierrez’s approach would be to do a Le Fort I horizontal maxillary osteotomy, in which the maxilla is disconnected from the rest of the skull and separated into three pieces: an anterior wedge-shaped section and right and left posterior portions. He would then reduce the vertical length of the maxilla and correct its asymmetry and reattach the shortened maxilla to the skull in its new position. If all went well the mandible would be able to rotate forward and re-establish occlusion.
Knowing that Mr Bengstom could be overwhelmed with the prospects of facing such intrusive surgery, Dr Gutierrez thought about how to present the possibilities to his patient.
This case reveals the complex interplay of technical objective and personal subjective factors. The task of the decision makers is to determine the benefits and harms of doing the surgery and those of avoiding it. Moreover, because there are alternative ways of doing the surgery, the benefits and harms need to be assessed for each. Deciding potential benefits and harms extends well beyond the scientific data. One of the most critical factors in this case may be the mindset of the patient. How well can he tolerate the mental agony of his present condition? How well can he handle the mental challenge of risky surgery? Likewise, in choosing among the variations in the surgical techniques, different subjective risks and benefits may be assessed differently depending on the character traits and values of the assessor.
This is a case in which resolution heavily depends upon the values of a significantly vulnerable patient. Clearly, such a person is severely compromised in his ability to objectively assess the alternatives presented to him. An important issue, therefore, is the extent to which the professional should help the patient participate meaningfully in the assessment of benefits and risks.
In such circumstances, the professional needs to be especially sensitive to how the possibilities for treatment are portrayed. Arguably, the doctor can never truly be in the position to fully understand the patient’s values and to know what is in the patient’s best interests.
Nevertheless, the doctor can look for ways to help the patient to at least lessen the harms associated with making a bad decision. The patient can be asked if there is a person or people who could participate in the discussion of treatment possibilities, perhaps a spouse, a parent, a sibling, a trusted friend, or a member of the clergy. Important information can be put in writing for future consideration. A second opinion can be suggested.
Even if the dentist and patient can determine the benefits and risks of the alternatives, the problem is not resolved. The dentist or patient (or both) may believe that there is a special duty not to harm. This could incline either of them to resist taking the chance of causing severe harm to the patient, possibly leading to a situation in which the dentist might insist on avoiding a risk of harm even if the patient thought the risks were worth it. Dr Gutierrez could plausibly believe that there is a serious risk of harm, but that, in his assessment, the benefits will be great as well. He could opt for the course that will maximize the net benefit, or he could give special weight to not harming the patient. Giving special priority to avoiding harm has very conservative implications. It would logically lead to never taking any risks. Most people prefer the moral stance of giving benefits and harms equal weight—mentally subtracting the harms from the benefits and choosing the course that produces the most net good. However, that still requires a subjective judgment about how much good will arise from the alternatives. Deciding whether to give special weight to avoiding harms is a matter of which ethical theory one uses. That is normally not part of a dentist’s expertise.
In this case, it sounds like the surgeon’s view is that for maximum impact on appearance and function, there is only one way to go. But in stating that, Dr Gutierrez ought to acknowledge that he is not considering other factors, such as risk of failure, risk of disease progression, and psychological effect on the patient.
However the conflict about how to relate benefits to harms is resolved, somehow the dentist and patient must determine what counts as a benefit or a harm. In dentistry the most relevant benefits and harms will be what we can call dental goods and dental harms, respectively. These are the benefits and harms that the codes of dental ethics normally have in mind when they commit the dentist to doing good for the patient.
Deciding what counts as a good or bad dental situation is more controversial than it may appear. Presumably an intact, functioning dentition counts as a good dental situation; caries lesions, missing teeth, pain, and vertical bone loss count as bad. But often the sorting of good and bad is much more complex. Is a well-functioning partial denture as good as natural teeth that are severely compromised? If not, how much worse is it? Is a time-consuming, expensive inlay better or worse than a four-surface amalgam restoration—and just how much better or worse? Does a well-functioning but discolored tooth count as bad in the calculation of overall dental good? If so, how bad? How does it compare with a crazed, chipped enamel surface that causes no problem now but probably is destined to in the future? How does one compare short-term and long-term benefits and harms?
During education in dental school, through the years of practice, and with the assistance of clinical research, certain patterns of answers begin to emerge that sometimes appear as a professional consensus. Often, however, patients may not share these judgments. This can lead to disagreements between patients and professionals about what is the best course of action to resolve a dental problem. It can even lead to disputes about whether a problem exists.
At this point, three closely related problems need to be distinguished. In some cases, a patient may concede that she agrees with the dentist’s judgment of what would be the best thing dentally. The patient may still disagree about the recommended course of action. She may, for example, acknowledge that a three-unit fixed partial denture is best but consider it too expensive. She may want to sacrifice what is best dentally for some other nondental good that is competing for her scarce resources to maximize her overall good. Cases like these will be discussed later in this chapter.
Another group of cases involves problems in which the patient and dentist agree about what counts not only as the dental good for the patient, but also as the overall good. Still, a patient might insist that he should have the moral right to act autonomously, to choose to sacrifice his own welfare. A parent who rejects a recommendation for a needed full-mouth reconstruction in order to save resources to use for his children might fit this situation, as might a patient who chooses to take a modest risk for a research project. This group of cases, in which autonomy and patient welfare are in conflict, will be the subject of chapter 8.
Still another group of cases involves conflict over the concept of the dental good itself. The cases presented here all involve disputes over what is best dentally for the patient. The disputes may arise between dentist and patient or between professional colleagues. The problem in these cases is to determine the extent to which there is an objective basis for deciding the best thing to do dentally and whether knowledge of dentistry alone can resolve the conflicts. These problems are illustrated in the following cases.
At the age of 35, Mrs Margaret Tilden resumed treatment in Dr Joanne Stump’s office. She had been Dr Stump’s patient 10 years previously and then had changed dentists. For a while she had been without care altogether. In the recent past her priority had been rearing her children. Dr Stump remembered her as someone who was quite fearful of dentistry.
Mrs Tilden’s oral condition was not good. She had several deep periodontal pockets and at some point a gingivectomy had been performed. Caries was extensive. Although no teeth needed extraction, restorative treatment would require endodontic treatment on four teeth and crowns on six teeth. Extensive periodontal care was also required. Even with this much attention, she might well lose her teeth later in life unless she significantly changed her home care practices and maintained regular dental care. Dr Stump thought Mrs Tilden would benefit from this care even if she ultimately required dentures.
Mrs Tilden wanted all of her teeth removed now. Root canal treatment was out of the question because of fear and also because of the expense. Dr Stump was definitely opposed to that plan, especially for someone Mrs Tilden’s age. From the standpoint of alveolar bone retention, the longer the dentures could be postponed, the better off Mrs Tilden would be.
Dr Stump considered whether to perform the treatment as requested. She also wondered how far she should go to convince Mrs Tilden to accept her choice.