Ethics Final [1] PDF
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Dr Asok Mathew
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This document is a lecture on dental ethics, focusing on the principles of beneficence and nonmaleficence. It discusses the dentist's duty to help patients and avoid harm, including analyzing case scenarios involving surgical decisions, interrupted treatment, and patient requests for interventions. The material explores the complexities of balancing technical objectives with the patient's values and preferences.
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Beneficence and Nonmaleficence Lecture – 6 Objectives of the lecture Describe the relation of benefits and harms. Distinguish between benefit and harm in different clinical cases. Determine a dental good and make decisions on the best thing to do dentally. Understand whether for...
Beneficence and Nonmaleficence Lecture – 6 Objectives of the lecture Describe the relation of benefits and harms. Distinguish between benefit and harm in different clinical cases. Determine a dental good and make decisions on the best thing to do dentally. Understand whether former patients and non-patients count within the framework of the dentist’s duty to benefit the patient. Discuss conflicts between the patients’ welfare and the total welfare of all persons who would be affected by the intervention. Principles The American Dental Association (ADA’s) Principles of Ethics and Code of Professional Conduct stats that “professionals have a duty to act for the benefit of others”. Under this principle, the dentist's primary obligation is service to the benefit of others. Beneficence is the principle that actions, and practices are right insofar as they produce good consequences. Non-maleficence is concerned with doing no harm to the patient. Challenges The decision regarding the level of pain that is acceptable to the patient must be determined by the patient. In some situations, the procedure may have what is known as a “double effect,” meaning that while the procedure fixes one issue, it initiates or causes another issue to arise. Exposure to blood products – doing good and avoiding harm. As in any medical profession, it is the obligation of the dentist to inform immediately any patient who may have been exposed to blood or any other potentially infectious material at the dental office. In addition, it is the responsibility of the dentist to immediately refer the patient to a qualified healthcare provider to obtain post-exposure services and follow-up. This includes providing information to the patient concerning the dentist’s own blood borne pathogen status and submitting to testing that will assist with the evaluation of the patient. If a third party is the source of the exposure, it is important that the dentist encourage that individual to cooperate as needed to properly evaluate the exposed patient’s condition Managing the correct relationship with patients Finally, under nonmaleficence falls the ethical obligation of the dentist to avoid interpersonal relationships with his or her patients. Incorrect relationships can impair a dentist’s ability to properly utilize professional judgment regarding treatment and may exploit the confidence placed on the dentist by the patient. The Relation of Benefits and Harms- differing opinions Some might consider that avoiding harm has a special moral priority over doing good. Doing benefits and avoiding harms equally weighty. A way of reasoning about benefits and harms is to calculate the ratio of benefits to harms. It is often termed as benefit-cost or benefit-harm analysis. CASE Scenario - 1 Case 1- High risk surgery Vs Continued disfigurement Mr. Carl Bengstom, age 38, was referred to Dr. Jose Gutierrez, an Oral and Maxillofacial surgeon at a large research-oriented hospital. Mr. Carl suffered from polydermal myositis, a connective tissue disorder with severe systemic effects. Therapy is largely palliative and, for Mr. Carl 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. Carl life was very difficult. 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. A choice between high risk surgery and continued disfigurement 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. Carl 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 which increased the risk of any surgery in the condylar area. There were two choices for Mr. Carl: 1) have nothing done or 2) undergo extensive maxillofacial reconstruction. A choice between high risk surgery and continued disfigurement The risks of failure of the surgery were high, especially because of Mr. carl 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 condyle which might act as a foreign body. Despite these risks, if surgery were done, there was also the possibility of a major improvement in appearance and function. Discussion - A choice between high risk surgery and continued disfigurement There is complex interplay of technical objective and personal subjective factors. The task of decision makers is to determine the benefits and harms of doing the surgery and those of avoiding it. Deciding potential benefits and harms extends well beyond the scientific data. One of the critical factors in this case is the mindset of the patient. How well he can tolerate the mental agony of his present condition? How well can he handle the mental challenge of risky surgery? Discussion- A choice between high risk surgery and continued disfigurement Clearly, such a person is severely compromised in his ability to objectively assess the alternatives presented to him. 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 lesson the harms associated with making a bad decision, by asking a parent, spouse or a trusted friend to participate in the discussion. The surgeon’s view is that for maximum impact on appearance and function, there is only one way to go. He is not considering other factors, such as risk of failure, risk of disease progression, and psychological effect on the patient CASE SCENARIO - 2 Case:2 - Interrupted Treatment Ms. Alice Andrews, age 55, entered Dr. Theodore Fuller’s practice wanting to save her remaining teeth. Dr. Theodore was a periodontist - prosthodontist with extensive experience in the use of implant. Ms. Alice main problem was in the maxillary arch, where she had only 6 remaining teeth, all in the posterior segments. All of her teeth had about 50% bone loss and required considerable periodontal therapy. When that was complete, Dr. Theodore planned to place two implants in the anterior segment and finish with complete maxillary reconstruction. Case:2 Interrupted Treatment Case: Interrupted Treatment Shortly after the periodontal treatment was started, Ms. Alice developed a brain tumor and under went surgery for its removal. Although it was malignant, it was thought to have been completely excised. However, she was left with a facial nerve deficient and the left side of her face was immobile. Ms. Alice returned to Dr. Theodore while she was still convalescing and wanted the treatment completed. Access to the oral cavity was extremely limited because of the paralysis, which made the technical aspects to the surgery and subsequent prosthodontics very difficult to perform. CASE 2 Interrupted Treatment Case: Interrupted Treatment Her teeth were more mobile than before and were even depressible, a finding that made the prognosis more questionable. As an alternative he could extract her teeth and fabricate dentures. less stressful for the patient the outlook for success was poor due to facial paralysis. Furthermore, Ms. Alice was determined to proceed with implants. Cases Discussion – CASE 2 Dr. Theodore, however, is concerned both about the prospects for clinical success with the implants and Mrs Alice ability to physically and psychologically withstand the procedure. To make matters worse, he also think that conventional prosthodontics will not work well either. There appear to be two very different ways to think about resolving this case. No way to determine objectively the best dental course. SURGEON’S DIALEMMA CASE SCENARIO - 3 Case 3 : Surgeon’s dilemma A 65 years old man with a history of cardiac problems was referred to an oral surgeon by a dentist in a rural community about an hour away. The dentist’s request was for the removal of one badly decayed molar. However, the patient asked that the surgeon also remove the adjacent tooth. The tooth in question had a large caries lesion, but it could have been easily restored. Referring to another dentist - about removing the adjacent tooth, the patient said, the surgeon could if he wanted, but it wouldn’t change anything as far as the patient was concerned Surgeon’s dilemma Case 3 The patient’s cardiac problem was limited to angina. There was no history of rheumatic heart disease or subacute bacterial endocarditis. The patient requested antibiotics, stating that all previous dentists had given him antibiotics. The surgeon knew that antibiotics were not indicated. He explained to the patient the reasons why they should not be given, but the patient was adamant in his request. With conflicts, both in the selection of teeth for extraction and the administration of antibiotics, the surgeon considered how to respond? Surgeon’s dilemma Case 3 - Cases Discussion It would appear that the dentist, as trained professional, ought to be able to determine what is best for the patient and that the patient is hardly in a position to disagree. However, patients do disagree, and for varying reasons. Keep in mind, that dentists often disagree with each other about the treatment plan that will bring no harm and good to the patients. Surgeon’s dilemma Case 3 Cases Discussion The question here is whether it is better dentistry in some objective sense to attempt the maxillary restorations even if it involves more time, pain, and psychic trauma. Is this simply a matter of taste and preferences, or is there some sense in which a dentist can say it is better dentistry to try the restorations first? Discussion If one views dentistry (and medicine) as a science, then such questions as implants versus dentures could be determined through clinical trails or other empirical research. And even if such evidence is not now available, the fact that it is agreeable to such an approach clearly suggests dentistry is a science. Cases Discussion- General points Cases Discussion Recent thoughts on these matters supports the idea that one can never conclude what is best for the patient strictly from scientific studies. Even after science establishes what the outcomes are likely to be, a value judgment still must be imposed on the outcomes. Science can never tell us which outcome is better; at best it can tell us what the outcomes are going to be. It is also necessary to build on that understanding to promote an atmosphere of mutual respect and forthright exchange of information so that the best possible clinical decision can be made. Thank you ….. Any questions …… Dealing Honestly with Patients – Veracity LECTURE -7 DR ASOK MATHEW LECTURE TOPICS Discuss the ethics of honesty and avoidance of lies. Recognize what is misleading & limited disclosure to the patient. Recognize the duty to disclose potentially meaningful information in the dentist- patient relationship as a two-way street. Veracity is defined as being honest and telling the truth and is related to the principle of autonomy. It is the basis for the trust relationship established between a patient and a health care provider. Patients are expected to be truthful about their medical history, treatment expectations, and other relevant facts. Clinicians, for their part, must be truthful about the diagnosis, treatment options, benefits and disadvantages of each treatment option, cost of treatment, and the longevity afforded by the various treatment options. Lying to patients does not respect the autonomy of the patient and can compromise the any future relationship the patient may have with health care providers. There are special cases, when it is morally debatable whether an exception might be made in situations where a lie or a shading of the truth could be justified because of the benefits to the patient. In these cases the question is whether the clinician should continue to pursue the patient's welfare or should deal honestly with the patient even if the patient will be worse off. Benevolent deception is the name given to the practice of withholding information from a patient because of the clinician belief that the information may harm the individual. Ethical approaches focus on maximizing net welfare. Now many health care professionals are questioning the ethics of lying to patients for their own good or for the good of others. The changes in attitudes have been so significant that there is currently a much greater inclination to disclose information to patients. Bold-faced Lies In relatively few instances, dentists may feel that they are justified ethically in telling outright lies to patients or to others. More often the ethics of honesty raises questions of not completely disclosing the truth. The cases in this chapter involve lies— statements made by dentists that they knew are false. Some lies seem clearly indefensible. Others are more debatable because the dentist could offer some moral defense of the lie. Case 1 – Lying to a child to avoid producing anxiety Luke Barddock was a 9 year-old child with a long history of dental experience. He had recently moved to a small Midwestern community and in the process his family had delayed establishing a relationship with a new dentist. When Luke’s father brought him to dr. Hansen, Luke had serious problems, the worst of which was an unsalvageable permanent mandibular first molar that was causing serious pain. Although Dr. Hansen didn’t like to consider extraction on a patient’s first visit, she determined that the extraction was necessary and need to be done immediately to give the boy some relief. Lying to a child to avoid producing anxiety Luke was moderately apprehensive about seeing a new dentist. He was trying to show courage. Finally, after the area was anesthetized, he asked dr. Hansen what she was going to do. Dr. Hansen had never been confronted so directly. She did not want to upset the child. After a short pause she said, “ I’m just going to look in your mouth”. At that point she was already approaching carefully from behind Luke’s head so the boy could not see the forceps. The tooth was extracted before Luke knew what was happening. Discussion There is no question that Dr Hansen meant well. She did not want to upset the boy by answering in a straightforward way that she was about to pull his tooth. If Dr Hansen were challenged to defend her lie, she probably would claim that she did what she believed was for the benefit of her patient. She was, no doubt, convinced that the boy would be terribly upset if told in advance about the extraction. If Dr Hansen really believed that the lie was the best thing for the boy in this situation, an ethic of patient benefit would support the lie. The question is whether there are any reasons why it would be morally wrong to say that she was just going to look when, in fact, she was going to extract. Discussion In this case, it turned out that the patient was so upset with the surprise that he was horrified at the thought of returning to Dr Hansen and was never able to see her again. Even for a dentist motivated by doing what was best for the boy, the possibility of psychological trauma should have been factored into the calculation of expected benefits and harms. Discussion Dr. Hansen may not have adequately considered the long-term consequences of lying. In this case, she may not have realized that Luke would be so traumatized that a long-term fear of dentists could cause serious harm for many years. It is wrong in the same way that breaking a promise or violating someone's autonomy is wrong—regardless of the consequences. The principle of veracity is sometimes considered along with the principles of fidelity and autonomy as part of the general ethic of respect for persons. In either case, the fact that one is intentionally speaking dishonestly counts as a moral wrong even if doing so produces better consequences. Misleading and limited disclosure Sometimes, however, there may be a duty to speak the truth even if not asked. In the consent process, we saw that many people believe that dentists have a duty to disclose what the reasonable person would want to know. A health professional who has an ongoing relationship with a patient, however, has a more stringent duty that may require disclosing all of those things that reasonable patients would want to know about their situations. Whether that duty is part of the principle of veracity ( TELLING TRUTH) or the principle of fidelity ( KEEPING PROMISES ) can be debated. Once a formal doctor-patient relationship is created, there is an implied promise of truthful disclosure that binds the parties. Case 2 – Non-Disclosure of Hepatitis Ms. Cheryl Grady was a dental hygienist who worked full time in a large office. Her employer. Dr. Donald Hollinger, became ill with hepatitis and was hospitalized for almost a week. Ms. Grady didn’t know what from of Hepatitis Dr. Donald had. However, she became concerned about the risk of transmission when the office manager told her that, per Dr. Donald’s orders, under no circumstances should she tell the rest of the staff about Dr. Donald’s illness. Case 2 Ms. Grady was quite concerned. In addition to all the patients with whom Dr. Donald had contact, he also had a staff of 12 people. Furthermore, he worked as an associate in two other offices. Ms. Grady though that Dr. Donald should inform his patients & staff about his illness. Ms. Grady called the city health department anonymously & without mentioning Dr. Donald’s name. Their opinion was that the dentist should not be working with patients. Mr. Grady discussed the situation with Dr. Donald, but he said that he badly needed the money, & could not risk disclosing his illness. Case 2 -Discussion Unless some curious patient asks Dr. Donald or Ms. Grady whether anyone in the office has hepatitis, no one will be telling an active lie. Still, questions of the ethics of communication arise. First, should Dr. Donald inform his staff and/or patients about his hepatitis? The staff is at risk. The problem could be viewed as one of the duty of an employer to inform his or her staff about risks in the workplace. To the extent that an employer generally has a duty to notify employees about significant risks, Dr. Donald's duty is no different from that of any other employer. Discussion Dr. Donald also faces the question of his duty to his patients. The dentist is obligated to disclose to patients the information they would find material in deciding to consent to treatment. In this case, the issue is whether reasonable patients would find Dr. Donald's hepatitis status relevant to their decision to agree to have him treat them. Some forms of hepatitis, particularly hepatitis B and C, are transmitted through blood contamination. A dentist who cut himself could bleed into the patient, who would then be exposed to the hepatitis virus. Although dentist-to-patient transmission is very rare, it can occur. The patients may wish to take the hepatitis status into account when deciding to remain in Dr Donald's practice. Discussion The Centers for Disease Control and Prevention (CDC) has considered the issue of viral transmission of blood borne HIV and has concluded that health professionals who ordinarily face no real risk of exposing patients need not disclose their HIV status, but that those performing high-risk procedures must disclose if they are HIV positive. Certain surgeons who face a high risk of scalpel or needle sticks are specifically mentioned, as are dentists. While the CDC has not made the same point with regards to blood borne hepatitis, the issues are identical. Fidelity- Obligations of Trust & Confidentiality Lecture 8 Lecture topics Determine the rights of a patient. Determine how high the standard of care for the patient should be. Recognize the ethical problems raised when the patient fails to fulfill his part of the contract. Understand confidentiality & the significance of trust. Recognize the ethical bond of loyalty to colleagues. Fidelity Fidelity can be viewed as the grounding principle for professions. Fidelity, along with the principles of autonomy and honesty, represent three different aspects of respect for persons. It rests on a certain trust and confidence that commitments made between the parties will be honored. The principle of fidelity can be understood to include the trust and commitment-keeping. Can we break the promises ? One's reputation will certainly be injured if word gets around that one cannot be trusted to keep promises. Even though there are often realistic reasons to keep promises, the ethically interesting situations are those special ones in which, more good is actually done by failing to keep one's word (e.g. refusing to extract a tooth of an uncontrolled diabetes patient although you promised him with the treatment before knowing he has the disease). Can we report the faulty ? Immanuel Kant was the most famous philosopher to hold that fidelity to promises is inherently one's moral duty regardless of the consequences. Commitments are made to the patients, profession and to fellow professionals. There are implied promises of loyalty and collegiality that can lead a dentist to want to protect a colleague who has made a mistake or lacks competence. There is also a commitment (in the words of the ADA's Principles of Ethics and Code of Professional Conduct) to provide "competent and timely delivery of dental care within the bounds of the clinical circumstances presented by the patient." The ADA goes on to say that "dentists shall be obligated to report to the appropriate reviewing agency as determined by the local component or constituent society, instances of gross or continual faulty treatment by other dentists." Is it a contract? The fiduciary relationship in professional ethics is sometimes referred to as a contract. It is part of the ethics of contracts that each party pledges something to the other. In legal contracts, when one party back out, the other party is normally excused from any obligation to keep his or her part of the deal. However, there is great controversy in professional ethics over the question of whether the relationship between the professional and the patient should be thought as a kind of contract. It cannot be reduced to a legalistic business deal. COVENANT The more appropriate term for the fiduciary relationship is covenant “agreement”. The term can be used to emphasize the moral and social character of the bond. One component is a general set of commitments to serve the patient or, to do what is best for the patient. This ethical commitment is so strongly represented in the tradition of health professional ethics that it can be said to be a promise made to the patient. Rights of a Clinician vs Patients Exactly what is entailed, however, is sometimes difficult to determine. Patients probably should be willing to wait short periods of time for appointments. Even for emergency care, they probably should be willing to wait until morning for all but not the most extreme emergencies. Another reason is that doing what is best may come at the expense of the rights of patients—their right to refuse treatment or their right to otherwise act autonomously. Taking the responsibility One set of problems growing out of our fiduciary relationship with patients is what should happen when the dentist recognizes that the care he or she delivered turned out to be less than ideal. When there are serious problems (such as a restoration that fractures), it seems obvious that the work must be redone. Who should bear the responsibility? When is care good enough? If the patient wants perfection, who pays? If the patient does not recognize the imperfection, should the dentist make a point of it? Case 1 Redo the case ? Dr. Paul Goldman had been practicing prosthodontics for almost 15 years. Except for a 0.5 mm discrepancy, the treatment he had given Ms. Debbie Richards was of textbook quality. However, because of that minor problem, he was considering redoing the maxillary arch. Ms. Richards was 55, and most of her teeth had been extracted. However, she very much wanted to keep the rest of them. Four mandibular incisors remained; her maxillary arch had only two central incisors, the left first premolar, both right premolars, and the right canine. Dr. Goldman made a mandibular partial denture and two maxillary fixed partial dentures. On the right side of the maxillary prosthesis, the remaining three teeth were crowned, and the lateral incisor was cantilevered as a pontic. The fixed partial denture on the left side used the premolar and both central incisors as abutments and the lateral incisor and canine as pontics. Therefore there was no connection between right lateral and central incisors. Case 1 Redo the case ? This was done to reduce stress on the first premolar that was already vulnerable in its role as a single-rooted tooth used for a terminal abutment. The provisional splints were cemented in as a single unit with all teeth connected. Initially, both he and Ms. Richards were extremely pleased with the result. The color was excellent, and all margins were flawless. The occlusion against the mandibular partial denture was perfect. Three weeks later Ms. Richards returned with a complaint. During chewing the restorations separated between the maxillary lateral and central incisors, which caused significant food impaction. Case 1 Redo the case ? It was very disturbing to have food trapped there when she was in a social situation. Dr. Goldman confirmed that the contacts between the right central and lateral incisors separated significantly during functional movements. He made some attempts to adjust the occlusion, but nothing worked. In retrospect, he felt he should have used precision attachments between the central and lateral incisors. He had avoided that because it would have required excessive bulk in that area. Discussion When Dr Goldman accepts a patient into his practice, he certainly commits himself to do high quality work. There is no evidence in this case that the problem should have been anticipated. He met his specific clinical commitment or promise and did it well, but an unexpected consequence occurred. Dr Goldman now recognizes that a modest problem exists. He would proceed differently were he to repeat the procedure, this time using precision attachments between the central and lateral incisors even if it would create additional bulk in the area Discussion How should he solve the problem of what to do for Mrs Richards? Consider the following positions that he might take: 1. Holding himself accountable to the standard of quality that his colleagues similarly situated would have provided. Then, if he judged himself deficient, he could redo the procedure at his expense. 2. He could also ignore what his colleagues might have done and hold himself accountable to doing the best possible work. This would mean redoing the procedure at his expense. 3. He can reduce his fee enough so that if, for some reason, the case must be redone, the financial consequences of charging a second time would be less for Mrs Richards, while at the same time would reduce his losses to a more acceptable level. Case 2 : When patient fails to pay the bills Ethical problems are also raised when the patient fails to fulfill his or her part of the contract. This question might arise if a patient fails to practice proper dental hygiene, persistently fails to keep appointments, or, as in the following case, does not pay his or her bill. Case 2 : When patient fails to pay the bills Ms. Sandra Lichter, who was in her late 50s, was a patient in the practice of Dr. Ana Burt. It was primarily reconstructive practice, and she has performed that type of service for Ms. Sandra. Ms. Sandra had received full mouth rehabilitation, consisting mostly of crowns along with one partial denture. Endodontic treatment and periodontal surgery had also been necessary. The total bill was expected to be about 20,000$. Dr. Burt had been paid 2,000$ by Ms. Sandra insurance company, and she had asked her business manager to arrange a payment schedule with Ms. Sandra. The business manager was sure that a business agreement had been made, but every time Ms. Sandra came in, she made some excuse for not paying. Case 2 : When patient fails to pay the bills Finally. The case was completed. Dr. Burt inserted all the restorations on a trial and was pleased with the result. However, Ms. Sandra still didn’t pay the 18,000$. Dr. Burt wondered whether she should withhold final placement of all restorations until the bill was paid or insert the prostheses and continue to try to work things out with Ms. Sandra Case 2 : When patient fails to pay the bills The first issue here is whether it is ever acceptable for a dentist to withhold the completion of work until the patient keeps his or her end of the deal. The ethic of contracts is that the parties bear mutual responsibility. Assuming both parties were competent and understood the nature of the agreement, if one party fails to fulfill her end of the bargain, the other party is not obligated to complete others. Is the dental relationship one in which the dentist bears moral responsibility for improving the dental health of the patient even if she cannot pay, at least if the reason that she cannot pay is beyond her control? Discussion Suppose that Dr Burt decides not to cement the crowns permanently. If, at a later time, the cast crowns, which have been cemented temporarily, develop problems caused by the washing out of the temporary cement and the subsequent development of caries, is Dr Burt morally responsible? Would such actions constitute abandonment? The ADA's position on abandonment is that "once a dentist has undertaken a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist." It goes on to say that "care should be taken that the patient's oral health is not jeopardized in the process." This suggests that the ADA is working with the more traditional model in which the fiduciary relationship with a patient requires completing the work regardless of the patient's willingness to pay. Confidentiality Health professionals have long recognized that they have a duty to their patients to keep confidential the information that they learn about the patient in the course of the professional relationship. The security felt by a patient that sensitive information disclosed in the course of treatment will be kept confidential by the dentist is a key feature of the professional trust relationship. There are two problematic cases. 1. First, should the professional disclose information when he or she believes disclosure would serve the patient's interest, even though the patient wants the information kept confidential? 2. Second, should the professional disclose information when such disclosure may prevent a serious harm to third parties? Loyalty to colleagues Fidelity also raises questions in relationships between dentists. There has long been a sense of a professional bond between members of a profession. It is important to ask exactly what this bond of loyalty to colleagues implies ethically, especially when it comes at the expense of patients. For example, dentists have sometimes felt obligated to protect colleagues who are incompetent, impaired, or otherwise substandard in their practice. Over and against this tendency, however, is a sense of professional duty to protect patients by reporting colleagues who provide substandard care. In addition, problems involving loyalty to colleagues are made worse by the lack of communication. Thank you Dr. Asok Mathew Lecture 9 Justice in Dental Ethics Basic principles - why justice ? Is it always ethical to do what will produce the most good when one patient is involved, versus doing good at the societal level. There is sometimes doubt that the morally right allocation of resources is to arrange them so that they produce as much good in aggregate as possible. Those who do not automatically accept that the aggregate good should be maximized believe that an additional moral principle must come into play—the principle of justice. Justice is a moral notion with a very long history. According to Aristotle, justice means giving everyone his or her due. The need for dental restorations normally would seem to be relevant when the distribution of dental services is being decided; race and gender seem irrelevant. General principles The general problem posed by the principle of justice is what should happen when there are not enough resources for everyone—not enough dentists, dental equipment, or funds to pay for dentistry. The principle of justice holds that sometimes the way in which the benefit is distributed counts morally. To each according to merit, ability to pay, or any other criterion would be different versions of justice-based allocations. Societal interest differ Between Specialties. Dentists as a group believed more resources should go to dentistry, physicians believed that more should go to medicine, and so forth. At the societal level, then, decisions must be made about how to spread the resources available to dentistry among the many dental needs. Dentists with different agendas are likely to disagree. Pediatric dentists may make a case for protecting children’s teeth; Geriatric dentists may likewise make a case for the needs of the elderly. Public health dentists may advocate prevention while restorative dentists may emphasize relieving the suffering of patients who already need interventions. Case Scenario 1 – Dental sealants on a limited budget In 1983 the National Institutes of Health created a consensus development panel on dental sealants as part of its ongoing project to assemble panels of experts to review matters of important public scientific controversy. The panel was made up of some of the country’s leading academic and clinical dentists, as well as a dental technologist, a lawyer who was a children’s health advocate, and a bioethicist. They were to assess the safety and effectiveness of the use of dental sealants and to make recommendations about their use. After recommending that public health dental officers give high priority to ensuring that the children in their communities had their teeth sealed, the question arose about what should be done when not enough funds were available to seal the teeth of all of the children in a given county. Reasons For technical reasons, children growing up in communities with a fluoridated water supply can make more efficient use of dental sealants. Because fluoride is especially effective in reducing caries on proximal surfaces, fewer Class 2 restorations will have to be placed and consequently fewer sealants will be destroyed. Arguments Would it be fair to purposely give the advantage of sealants preferentially to children in communities where the water supply was fluoridated? It is surely not the fault of the children in the communities without fluoridated water that their teeth do not get fluoride protection. Moreover, some of those children actually get fluoride through application by their dentist. Still, it would be terribly inefficient for a school-based program to identify those children who are treated privately and to seal only their teeth. Arguments Should the dental sealant panel recommend that limited funds for public sealant programs go to the children who can be treated most efficiently? Should these children get the funds even though they are already better protected (for proximal caries) and even though it is not the fault of the other children that they do not have fluoridated water supplies? Or do all children under the jurisdiction of the county public health dental officer have rights of access that should not depend on their parents’ decisions about their water? If so, because it is impossible to seal all of the children’s teeth, which children should get priority: those with the greatest economic need, those with the worst teeth, or those selected at random? Discussion Sometimes it might be more efficient to treat a certain Gender, Race, Ethnic group, Age group. When the specific facts of the situation make discrimination more efficient in terms of improving overall community health statistics, those who accept social utilitarianism—that is, those who apply only the principles of beneficence and nonmaleficence—will intentionally choose the most efficient allocation, even though it is discriminatory. The dentists on the panel who were utilitarian favored giving priority to the children in the community-based fluoridation programs.. DIFFERENT VIEWS Other members of the panel, including the patient’s rights–oriented attorney and the bioethicist, insisted that the principle of justice had to be considered. They argued that the principle of justice would require a policy in which all children had an equal chance at getting the sealants—even though it is less efficient and fewer caries would be prevented. Case 2 Children versus Adults An eastern state has an annual dental Medicaid budget of $7.6 million. Of that amount, $5.1 million is allocated for children and $2.5 million is allocated for adults. Currently, comprehensive care is mandated for children, whereas funding for adults is almost exclusively for emergencies. A major problem of the Medicaid program is that access to care for children is very difficult despite the mandate for comprehensive care. This is because the state’s Medicaid fees are so low that it is difficult to find providers. In fact, this state’s fees are among the lowest in the country. Children versus Adults The program’s dental director was considering a way to get more providers for children. He could eliminate the adult program and transfer the money to the children’s program to raise the fees, making it easier to attract providers. He figured that he could probably get approval for the proposal if he decided to put it through. He considered the pros and cons of making this move DISCUSSION Children versus Adults They may establish beneficial patterns that would make the benefits of childhood dentistry large in comparison to the costs. Along this line of reasoning, if the $2.5 million spent on adults could do more good if it were spent on children, then the switch should be made. However, some interventions done for children may not be that efficient. Especially for interventions that affect primary teeth, the length of the benefit will be much shorter. Sealing primary teeth, for example, is not as efficient as sealing permanent teeth. If we opt for the straightforward effort to maximize the good, some children may actually lose. Discussion - Children versus Adults An elderly person who has had good dentition all her life but is now experiencing moderate tooth mobility related to bone loss might be thought to be better off than a child whose immediate problem with caries is less severe, but who will have to live a long life with the problem. Regardless of how the question of age is settled, those committed to the principle of justice want to determine which patients are worst off and use the limited Medicaid funds to meet those needs. CASE 3 ETHICS OF LICENSURE In recent years, opposition to the current system of dental licensure in the United States has grown significantly. As dentistry is the only health profession to perform invasive, irreversible procedures on live patients for licensure, resolutions for the elimination of live patients have been passed by the American Dental Association (ADA), several state dental associations, the American Dental Education Association, and the American Student Dental Association. At least one state has granted licensure simply upon completion of a program in general dentistry. In addition, opponents have challenged the very idea that any state or regional testing board ought to pass judgment on clinical competence; they believe that graduation from an accredited dental school should be sufficient. Arguments Multiple radiographs taken during the license exam. Despite the usual practice of not requiring patients to pay for procedures, it is a widespread practice for candidates to unofficially pay their patients for their time and inconvenience. In addition, every time a board exam is given, it seems that one or two students fail simply because their patient broke an appointment. Furthermore, opponents say, the system does not really serve to keep incompetent dentists from practicing.. Arguments People who fail the exam just retake it until they pass. Finally, some skeptics say that the use of live patients is no longer necessary. Modern patient simulators have been available for some time and are used in many dental schools, even though their usefulness may be mainly to test manual dexterity. Others say that what might work is a method where live patients are used only in the context of an educational program/ in a university set up that better ensures patient safety, follow-up care, and the appropriate sequence of treatment. Discussions The use of live patients in the licensure process raises many issues. Some of them could potentially be addressed without eliminating the use of live patients in the exam. Abuses in retaking radiographs, for example, might be prohibited. Failing students because a patient misses an appointment seems to be an issue that could be addressed. Only a particular members of the society who end up as the patients for the examinations is considered injustice and unethical. Thank you Lecture 10 Incompetent, Dishonest & Impaired Professionals Lecture topics 1.Discuss the meaning of incompetent, dishonest and impaired professionals. 2. Recognize and distinguish between significant and marginal incompetence by colleagues. 3. Identifying and dealing with fraudulent, dishonest and illegal practice. 4. Identifying and dealing with impaired dentists. Introduction Some dentists practice dentistry incompetently. Their intentions may be good. Perhaps at one time these dentists had good skills, but time has passed them by. While others may never have been practicing up to standard, but they somehow graduated from dental school and became licensed to practice. The ADA says that all dentists "have the obligation of keeping their knowledge and skill current." In rare cases dentists may not lack competence but nevertheless may engage in fraudulent, dishonest, or illegal practices. These could range from filing fraudulent insurance claims to lying to patients to prescribing illegal drugs. While these actions are clearly unacceptable. They pose difficult problems for colleagues committed to protecting the integrity of the profession. The dentist who observes an incompetent, dishonest, or impaired colleague has an obligation, a duty to report a colleague or to take other action to see that patients are adequately protected. The ADA holds that "dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists." The ADA seems to recognize the legitimacy of informing patients in some cases but warns that the dentist should do so in a way that is not critical of a colleague's practice: "Patients should be informed of their present oral health status without disparaging comment about prior services." Incompetent dental practice From time to time, a dentist unfortunately sees a colleague's work and finds it to be substandard. Sometimes the dentist is honestly unsure just how substandard the colleague's practice is; there is legitimate room for professional disagreement about treatment strategies and the standard of adequate skill. Other times it is clear that a colleague's practice is grossly inadequate. Case 1 – Broken file Mr. George Sakonis was referred to Dr. Marvin Goldberg, an endodontist, for treatment of a mandibular first molar. The referring dentist had been treating the tooth unsuccessfully for several weeks using both instrumentation and the prescription of two or three different antibiotics. Dr. Marvin examined Mr. Sakonis and found that a broken file had been left in one of the canals. The referring dentist had not told him about it and probably had not told the patient either. Although in this case the broken file was probably not the source of the pain, its presence was disturbing nonetheless Dr. Marvin plan was to inform Mr. Sakonis of his findings, to open the canal to begin treatment, and to begin antibiotic therapy with a different agent. When he told Mr. Sakonis about the file, Mr. Sakonis became extremely agitated. He could not understand why he had not been referred to the specialist earlier. He said he was going to demand that the referring dentist pay for his treatment and also for the work time that he had lost during this course of treatment. Dr. Marvin had often been put in a similar situation. However, Mr. Sakonis situation was more troublesome than most. Dr. Marvin considered what his ethical position was in relation both to Mr. Sakonis and to the referring dentist Dr. Marvin, has concluded that a colleague's work is significantly substandard. He would acknowledge that breaking a file is something that even a competent dentist can do, failing to recognize the broken file, to inform the patient, and to treat the problem is a significant error. Who is at risk here and what are the dentists' options? Dr. Marvin was reasonably frank in describing the current clinical situation to his patient. The effect of his disclosures was predictably upsetting. He might, in retrospect, has considered not fully disclosing what he saw. That would have made his life easier, but it hardly agrees with the principle of veracity. Additional questions arise concerning whether a dentist who discovers a colleague's poor work should speak directly with the offending dentist and, if so, should attempt to get the patient's payment refunded. Discussion Whether Dr. Marvin should approach the offending dentist may turn out to depend on the circumstances. If the colleagues are believed to be naïve about their in competencies, diplomatic communication might be productive, but if these dentists have histories of grossly inadequate work, then a more aggressive response may be called e.g. reporting them to a licensing board. Considering the risk for future patients, these dentists seem to have a moral duty to go beyond discussion with the offending colleague to ensure their practice improves. If increasing the dentist's awareness of his or her inadequacies is unlikely to bring about change, there may well be a duty to report him or her, depending on the circumstances, to the local dental society or the state licensing board. The dentists' general obligation seems quite clear: Whether they approach the offending dentist, take action through professional channels, or "go public," they have a moral duty to do something to ensure that these and future patients are protected from grossly inadequate practices Marginal incompetence Often, colleague's work presents a more borderline problem. For instance, a clinician's work is routinely slightly substandard or reflects slightly out-of-date technique, or the colleague is generally known to do excellent work but has made a significant mistake in a single patient. Case 2 A periodontist sees another periodontist's case Mr. Robert Stilwell, age 56, had been under the care of a periodontist, Dr. Theodore Petrovish. Recently Dr. Theodore had told Mr. Robert that his disease had progressed to the point where his teeth should be extracted and dentures made. Mr Robert was desperate to save his teeth and asked his general dentist if something could be done. His dentist referred him to Dr. Joseph Donofrio, another periodontist, for consultation and treatment. Dr. Joseph agreed that Mr. Robert condition looked bad. Despite the possibility that Mr. Robert home care may have been questionable, Dr. Joseph thought that Mr. Robert probably and been mistreated by Dr. Theodore. In Dr. Joseph opinion, diagnosis had been in-complete and his treatment had been ineffective. Case 2 Although a case could be made for complete dentures, Dr. Joseph could see that with selective extractions and the use of implants, followed by fixed partial denture treatment, it might be possible to save Mr. Robert dentition. It was a costly and lengthy treatment, but it could be done. Dr. Joseph’s problem at this point was what to tell Mr. Robert. He did not want to create unnecessary problems with Dr. Theodore, whom he viewed as a colleague, but he felt that he had to be honest with Mr. Robert about his condition. Discussion The ethics of truth-telling is the point at which Dr Joseph appears to feel that he must start. The patient, Mr Robert, did not specifically ask Dr Joseph whether he would recommend the original treatment plan; Mr Robert wanted only to keep his teeth. Dr Joseph could try to mask the problem by claiming that if he did not say anything he would not be lying, only withholding the full truth. While in some relationships, one need not to say everything he/she knows, in the fiduciary relationship between dentist and patient, the professional is in a position in which he or she knows things that the layperson could not be expected to know. There is a trust that requires that the professional communicate openly Discussion The principle of fidelity, is also relevant here. Dr Joseph is committed to tell Mr Robert what he would reasonably want to know as part of the consent process. Dr Joseph may also have professional bonds with his colleagues. A professional, cannot have an obligation never to contradict a colleague's judgment. He cannot feel obliged to refrain from speaking critically of a colleague's work if he is convinced that it is substandard. Even if he believes that a case can be made for complete dentures, that cannot mean that he should refrain from presenting other options. The alternative needs to be presented, especially because Mr Robert wants to save his teeth. Fraudulent dentists / Illegal Practice It is clear that some dentists practice substandard dentistry solely for their personal gain in ways that are dishonest, illegal, or both. The following cases look at such practices. Case 3; Should the surgeon suggest dental implants ? Mr. Walter Baron was a businessman in his early forties who lived in the northeastern US. His dentist referred him to Dr. Allan Wagner, an Oral surgeon, for the removal of a mandibular premolar. The tooth was painful and had a history of unsuccessful treatments. Dr. Wagner agreed that extraction was necessary. Before extracting the tooth, he asked Mr. Baron what the subsequent treatment was going to be. Mr. Baron replied that a three unit fixed partial denture was planned. Dr. Wagner saw that neither of the abutment teeth was compromised with caries or restorations. Because of these facts, it appeared to him that an implant would be a good alternative for Mr. Baron. CASE 3 Dr. Wagner had placed many implants with good success, but he knew the referring dentist had never done implant therapy and in fact knew very little about it. Recommending an implant to Mr. Baron almost certainly would irritate the referring dentist. Dr. Wagner might also be accused of conflict of interest because he was the only local oral surgeon who performed implant therapy. Yet he thought that it would be a good treatment and seriously considered discussing the implant with Mr. Baron. Discussion The key questions here are why the referring dentist recommended the three-unit fixed partial denture and why Dr Wagner prefers the implant? The referring dentist might believe that the fixed partial denture is the only option available, in which case there is a competency issue. On the other hand, he might realize that an implant is possible but wants to keep Mr Baron as his own patient to gain the income from providing the fixed partial denture. If that is the case, the issue is not competency, it is honesty. Likewise, Dr Wagner might favor the implant because he really believes it is the best option, but he might merely want to perform the treatment to gain the income. If either dentist is pressing his choice to keep the patient for himself, it seems clear that self- interest has overpowered concern for patient welfare. One option would be for Dr Wagner to present the options to Mr Baron and then to let him choose. That would seem to be consistent with the principle of autonomy and informed consent. Grossly dishonest behavior In the previous case it was not clear whether the referring dentist was simply incompetent (lacking in knowledge) or was motivated by self- interest. The following case, however, involve clearly and obviously dishonest practices that raise the question of how a colleague should respond. Thank you LECTURE 11 Case Discussions Treatment Alternatives and Their Risks and Benefits The following cases present consent situations in which dentists must decide what to disclose. Using the professional, reasonable person, and subjective standards discussed in the previous section, what information should these dentists disclose to their patients? Case 1 What counts as risk? Ever since the safety of amalgam became a public controversy in the 1990s, a good number of Dr Barnes’s patients had raised concerns about the amalgam restorations that he had put in their teeth. They feared that mercury from the restorations might precipitate any number of immunologic disturbances, including multiple sclerosis. Justification Dr Barnes was not happy about the prospect of removing the amalgam restorations that he had placed over the years. Amalgam had been in use for more than 100 years and was being improved upon all the time. Furthermore, he felt that the alternative materials, despite significant improvements, were often still less satisfactory than amalgam. He decided to take the position recommended by the ADA. Action He would remove the amalgam restorations if requested by his patients, but only after a thorough discussion about the problems of the alternatives. He felt that the absence of definitive evidence of harm did not necessarily certify that the amalgam restorations were completely harmless. Discussion One of the elements of informed consent is an explanation of the treatment options. Thus, Dr Barnes must decide whether to present the alternatives to the use of amalgam. To resolve his dilemma, Dr Barnes can decide whether to follow the professional standard or the reasonable person standard. If he uses the professional standard, it is clear that he could follow the path recommended by the ADA and taken by the great majority of his colleagues. Case 2 Mrs Dorothy Wolfe was 40 years old, lived in a wealthy suburb of a large midwestern city, and knew that she needed periodontal care. Because she was insured by a major insurance company, she checked her roster of participating periodontists and selected Dr Margaret Wozniack from a list of three. case 2 On her first visit, Dr Wozniack explained that Mrs Wolfe needed extensive scaling and curettage. This would be accomplished in two more visits. The cost would be $75 for the diagnostic visit and $450 for each of the other two visits, for a total of $975. After each visit, Mrs Wolfe paid $225; her insurance would cover the rest. The treatment went well. However, Mrs Wolfe never saw Dr Wozniack after the initial consultation; the entire treatment was done by the hygienist. This bothered Mrs Wolfe, but she was unsure about the standards of treatment and never complained. While paying after the last visit, the receptionist said that Dr Wozniack wanted to see Mrs Wolfe in a month for a follow-up visit. Mrs Wolfe agreed. On her return she was pleased that Dr Wozniack actually examined her, checking both her periodontium and her occlusion. As Mrs Wolfe was leaving, the receptionist informed her that she owed $125 for the visit. Mrs Wolfe angrily refused to pay, saying that it was not part of the original treatment plan. She discussed her complaint with the peer review committee of the dental society. The committee chair then called Dr Wozniack to try to arrive at an equitable settlement. CASE 2 Points to defer whether they would have mentioned the cost of the follow-up visit, the fact that the hygienist would perform all of the treatment proposed, any variations in what could be done for Mrs Wolfe. Who will perform the treatment A second element of informed consent: an explanation of who will perform the procedures. When Mrs Wolfe agreed to the proposed treatment plan, she apparently assumed that Dr Wozniack would perform the procedures and may well have based her judgment about the reasonableness of the cost on that assumption. If someone other than the dentist will perform any of the procedures, the patient has a right to understand that fact. Sometimes it may be obvious, as when a hygienist provides routine scaling and cleaning, but in other cases a patient would have no basis for knowing. An informed consent must include adequate understanding of who will perform all aspects of the care. Adequacy of informed consent Finally, the case introduces a third element of an adequately informed consent: accurate information about the charges. It seems clear that if Dr Wozniack planned to include a follow-up examination in the treatment plan, it should have been disclosed to Mrs Wolfe as part of the overall proposal with the cost included so that she could agree to the total anticipated fee. Only those elements that legitimately could not be anticipated in advance should be added to the treatment plan at a later time. Differing Views of Treatment Options Held by Other Dentists Case 3 Tammy Williams, an 8-year-old patient of Dr Bob Zarnecki, was referred to Dr Joe Corbin, a pediatric dentist, for removal of an abscessed mandibular primary molar. Tammy had become very upset when Dr Zarnecki had attempted local anesthesia. At first he referred her to an oral surgeon for extraction under general anesthesia. However, Tammy’s mother, Mrs Williams, refused because her sister had almost died while having extractions under general anesthesia. Dr Zarnecki then referred Tammy to Dr Corbin for the extraction with nitrous oxide conscious sedation, no other treatment being necessary. Case 3 ( continued ) Dr Corbin’s examination confirmed the presence of a draining abscess. He explained the risks of nitrous oxide and how it differed from general anesthesia. Mrs Williams was still apprehensive and authorized its use only if absolutely necessary. On the day of the procedure, nitrous oxide was, in fact, necessary. However, the extraction occurred without significant incident. During the treatment Dr Corbin noted that the first permanent molars were deeply grooved and somewhat hypo plastic. They needed sealants. Dr Corbin knew that Dr Zarnecki did not use sealants because he did not think that they worked. Dr Corbin wondered whether he should tell Mrs Williams that he thought that sealants were highly indicated for Tammy. He knew that if he did, he would most likely offend Dr Zarnecki. Dr Corbin decided to state his views. He explained that sealants have been proven to prevent decay but that not all dentists used them. However, because Tammy was quite fearful of injections, he advised that she have the sealants applied. Discussion- toxic effects of nitrous oxide vs general anesthesia Here two different consent issues could be singled out for special attention. First, Dr Corbin needs to determine what information to transmit in regard to treatment alternatives—what he should say about 1. local anesthesia, 2. nitrous oxide, 3. and general anesthesia options. There may be other treatment options or variations on these options that might be disclosed under any of the three standards. It is clear that the risks of general anesthesia and nitrous oxide need to be discussed, Dr Corbin probably should discuss the use of local anesthesia as well. Local anesthesia for dental procedures is familiar to most people and its successful use is so widespread that it is generally considered safe by the public. Yet, as with any agent, it can cause problems that include toxic effects, allergic reactions, and even death. On the other hand, the toxic effects only occur when local anesthesia is used in excessive quantities; the frequency of any kind of allergic effect is less than 0.0001% and the frequency of death is approximately one death per trillion injections. Discussion ( contd.) A dentist might conclude that a risk of one per trillion is so remote that reasonable patients would not find the information relevant to their decision to consent. Still, Mrs. Williams’s unusual concern may require disclosure based on the subjective standard. The second consent issue concerns the sealants. Under the professional standard, the appropriate question is whether other pediatric dentists receiving such referrals would raise the sealant option. Knowing that the referring dentist does not use sealants might dissuade dentists from raising the issue. One value taking over other value of ethics If Dr Corbin decides that Mrs. Williams would want to know about the sealant option, bringing it up could involve an apparent conflict with the ADA’s Principles of Ethics and Code of Professional Conduct, which states that only the treatment that is requested by the referring dentist should be performed on referred patients. Because the ADA Code also commits the dentist to working for the patient’s welfare, this may be a case in which Dr Corbin must violate one or the other of the Code’s provisions. Selling commercial items for profit These special—and conflicting—interests include the subtle daily interactions of practicing dentists with their patients, in which recommendations to patients are made under the obligation of beneficence but also materially benefit the dentists. In addition, they include the special interests of dentists who sell commercial products to their patients for profit, own dental laboratories, consult with dental products manufacturers, or invest in pharmaceutical companies What Procedures, if Any, Are for Research Purposes If a dentist is involved in clinical research—either formally, as part of a funded investigation, or informally, to satisfy the dentist’s curiosity— informing the patient of which procedures are undertaken for research purposes constitutes an additional element of an informed consent Casa Pia study on dental amalgam The University of Washington collaborated with the University of Lisbon in Portugal to do a study funded by the National Institute for Dental and Craniofacial Research (NIDCR). The topic of the study was the safety of dental amalgam, a longstanding problem that still had no definitive resolution. Although government panels still recommended the use of amalgam in the absence of good evidence of harmful health effects, they also pointed out that more research on health effects was necessary. Casa Pia study on dental amalgam The children would be randomly assigned to two groups, one of which would receive amalgam for the restoration of large posterior lesions, with alternative materials (mainly composites) used elsewhere. The other group would receive alternative materials for all lesions. Each year, all of the participants would undergo a number of neurobehavioral and neurological tests as well as urinary mercury analyses. The study was ready to begin when an ethicist on the Data Safety and Monitoring Board expressed concern about the consent process. About 20 percent of the Casa Pia students were wards of the state, either because of their status as orphans or because of unstable family situations. For these students, the director of the Casa Pia school system was authorized to give consent—one person for about 170 children! Casa Pia study on dental amalgam This case poses several important consent issues. The first is determining which elements of this intervention are research and how to explain that to the parties responsible for the consent. One may view the use of amalgam materials as a current standard practice, so the mere fact that the children in the experimental group would receive amalgam does not constitute research. Alternatively, if the concerns about amalgam were so great that they were no longer classified as standard practice, then they would have to be described as research interventions. Of course, even if the amalgam restorations were considered standard practice, the treatments would still require consent just like any other therapy and the controversy over the risks of amalgam would have to be presented Casa Pia study on dental amalgam At least two features of these interventions appear to be research—that is, undertaken for the purpose of producing generalizable knowledge. The randomization of children to receive amalgam or composite for their posterior lesions is the first. The subjects and their surrogate, the director of the Casa Pia school system, need to know that they are being assigned at random to a treatment group. This is something that would never be done in routine therapy; it potentially undercuts the clinician’s judgment about which of the two materials is preferred in individual cases. Presenting the risks of these two options is also complex. If amalgam had been questioned (which is the premise that led to the study), then its suspected risks must be presented, but any potential risks of the composite must be presented as well. Labeling any of these risks as “research risks” will depend on whether one considers one or the other treatment a deviation from standard practice. Casa Pia study on dental amalgam The second major intervention that is research and must be identified as such is the neurobehavioral and neurological tests and urinary mercury analyses that will occur once the restorations have been placed. Both the students and their surrogate need to know that these procedures are not required for regular therapy. Even if the investigators can properly identify those interventions that constitute research, they still need to determine whether they have an adequate consent process. Legality and standards- Casa Pia study on dental amalgam Since this study is taking place in Portugal, it must meet all Portuguese requirements. But because the research is being conducted by the University of Washington and is funded by the NIDCR, it must also meet American standards, including approval by the University of Washington institutional review board, which governs all of its research, and by the NIDCR. The subjects of this study are children between 8 and 10 years of age. They cannot themselves give an adequately informed consent, but they can be expected to give their assent and should be excluded from the study if they refuse. Casa Pia study on dental amalgam Because the study involves research procedures on patients who cannot themselves give consent and because it involves some potential risks (including the risk of exposure to mercury from the amalgam when other treatment options were available), there is controversy over whether parents or guardians can give consent or permission for their children to enter the study, The American norm is that parents can give permission provided that the risk is related to treatment for a condition from which the children suffer and is only a minor increment above the risks of ordinary life. Because the children have caries lesions and the risk of the amalgam is, at most, minor, the study seems to meet this standard; the parents could give permission if they wanted to. Casa Pia study on dental amalgam The problem is more complex for the children in the Casa Pia school system who belong to a particularly vulnerable group—orphans or children otherwise separated from their families. Relying on a surrogate, even a legal guardian, to approve the children’s entry into a research project is controversial. Some hold that it is only permissible if the study could not be done on children from intact families. Others hold that it can include vulnerable subjects, provided that other children from intact families are included as well. The safest course would have been to exclude those Casa Pia children who were wards of the state and any others who do not have parental involvement in the consent process Response to consent & refusal of consent Informing a patient and asking for consent to treat implies that the patient has a right to accept or refuse the suggested treatment plan. Sometimes patients may respond in an unexpected manner; they may refuse to consent to the recommended treatment plan. The following case raises the question of how the dentist should respond to a patient’s refusal of treatment. Surgery for Jehovah’s witness Mrs Wilma Allen, a 42-year-old single black woman with no dependents who 207 was employed as a secretary, consulted Dr Richard Jaeger, an oral and maxillofacial surgeon, about a large swelling in her left cheek. A panoramic radiograph showed that the sinuses were cloudy. Examination of a biopsy specimen revealed a large amount of dysplastic fibrous tissue, and the lesion was diagnosed as reparative giant cell granuloma. The indicated treatment was surgical removal. Surgery for Jehovah’s witness Two complicating factors existed. One was that Mrs Allen had sickle cell disease; her hematocrit was 15, and her hemoglobin was 5. The other factor was that Mrs Allen was a Jehovah’s Witness. Although she had no objection to the surgery, under no circumstances would she consent to receive blood products. Her position was absolutely firm. Dr Jaeger talked with Mrs Allen about what would happen if nothing was done—the lesion would grow larger and become more disfiguring. He also told her that removing the lesion without her authorization for a transfusion, considering her serious involvement with sickle cell disease, could result in grave consequences, even her death. Even so, Mrs Allen refused to change her mind. Dr Jaeger discussed the matter with members of her church and they all agreed with Mrs Allen. Mrs Allen was willing to have the surgery done, but Dr Jaeger was extremely reluctant to do it. What should Dr Jaeger do? Surgery for Jehovah’s witness The problem with this consent conversation is not in determining what the patient should be told, but in how to respond once the patient has refused what seems to be the treatment that is in her best interest Surgery for Jehovah’s witness Jehovah’s Witnesses believe, based on scriptural interpretation, that receiving foreign blood excludes them from eternal salvation. Moreover, in some cases, the receipt of blood can lead to terrible psychological sequelae and sometimes social ostracism. From Mrs Allen’s point of view, the transfusion really may not be in her best interest. Surgery for Jehovah’s witness What about Dr Jaeger’s point of view, however? We have seen that from the traditional patient-benefiting perspective, one might argue either way. From the standpoint of autonomy, however, Dr Jaeger should respect Mrs Allen’s right of refusal. This respect for autonomy is required by law and widely accepted as the ethically appropriate choice. What are his options if he decides to honor Mrs Allen’s refusal of a transfusion? He could do the surgery and be prepared to use blood substitutes if necessary, a position acceptable to most Jehovah’s Witnesses. He could consider obtaining some of Mrs Allen’s blood in advance for use in autologous transfusion. In this case, however, he would need to find out if Mrs Allen considered this acceptable. The more difficult question is whether Dr Jaeger could, on grounds of conscience, send her away if she refuses to accept his recommendation for surgery with transfusion if necessary Autonomous choices and incompetent patients The previous case dealt with refusal of treatment by an adult who was presumed to be mentally competent. In other situations the patient is clearly not competent, but someone must still decide what should be done for the patient VACILLATING PARENTS Adults, while they are competent, often designate surrogates through a mechanism called the durable power of attorney. If the patient has designated a surrogate, that person clearly seems to be the best choice. In extreme cases courts will review the surrogate’s choices and overrule them if necessary, but normally the decision of the one so designated for medical choices will prevail. Vacillating parents Dr Joan Smith, a pediatric dentist, was examining Joey Daniels, who at age 2½ was a heavy 31 pounds. Joey had no medical problems, but he had a history of nursing-bottle caries. He was brought in because of continued problems related to that diagnosis. Joey was also proving to be a severe behavior management problem. Examination showed that two maxillary incisors were abscessed, and the caries on the other two were so extensive as to make them virtually un-restorable. Radiographs were impossible to obtain because of Joey’s behavior. Dr Smith’s customary policy was to orally present a proposed treatment plan, including explanations of risks and alternatives. When she was satisfied that the parent understood and agreed to the proposed treatment, she then proceeded without obtaining written approval Vacillating parents Dr Smith followed this policy with Joey’s mother. She explained to Mrs Daniels that the best choice was the extraction of all four incisors. Although two of the incisors might be saved, it was very unlikely that the restorations would hold up over time. Dr Smith told Mrs Daniels that it would be necessary to give Joey a sedative and prescribed chloral hydrate (60 mg/kg) and Vistaril (1 mg/lb, maximum of 25 mg). She also explained that the effectiveness of the sedative was quite unpredictable and that it only worked well approximately half the time. In any case, it would be necessary to use nitrous oxide to supplement the sedation. Finally, Dr Smith explained that some physical restraint was necessary and that Joey would be wrapped in a blanket (Pedi-Wrap) to keep him from moving. Mrs Daniels seemed to understand the procedures and verbally agreed to the treatment plan. Dr Smith scheduled Joey for an early-morning appointment the following week. Vacillating parents At that appointment, Dr. Smith administered the sedative agents. Then, just as she was ready to anesthetize the teeth, Mrs Daniels said she could only afford the extraction of two teeth and that Dr Smith should remove only the two worst ones. Dr Smith could not believe what she was hearing. Everything was ready, and Mrs Daniels was saying to do only half the treatment. Dr Smith quickly explained the situation and told Mrs Daniels not to worry about the money at this point; something could be worked out. The important thing, Dr Smith said, was that Joey was sedated and should not have to undergo multiple sedations. Mrs Daniels responded by questioning whether all four teeth really needed to be removed, but she finally agreed, and Dr Smith proceeded. Vacillating parents Joey screamed, kicked, moved his head back and forth, and sweated profusely. Even after the Pedi-Wrap was put on, Joey required restraint. Dr. Smith administered nitrous oxide and increased it to 50% but saw that it was not helping. She therefore gave 100% oxygen to flush out the nitrous oxide and decided to go ahead as best she could Dr. Smith anesthetized the teeth, inserted the Molt mouth prop, and extracted all four teeth. The procedure was without incident except that bleeding was difficult to control at first. Surprisingly, she paid the entire fee. Later that morning, Dr Smith received a call from the office manager of a pediatric dental practice located in the general vicinity. Mrs Daniels had called them with a request to be seen because her child was bleeding. She had also told them that Dr Smith had extracted some teeth that did not need to be removed, and she requested a second opinion. Dr Smith called Mrs Daniels at 1 PM to discuss the situation, including the bleeding problem. She offered to see Joey but explained that some oozing from tooth sockets was normal. During the conversation Mrs Daniels accused Dr Smith of extracting good teeth, while Dr Smith tried to explain that, in fact, they all needed to be removed. Vacillating parents The first issue is whether Dr Smith told Mrs Daniels what she really needed to know: Even if removing all four incisors was dentally best for Joey, did Dr Smith realistically convey all the options? Two teeth were virtually unrestorable but might have been saved. Vacillating parents The next problem, assuming there was an adequate disclosure, is whether there was a valid consent. There was no written consent; legally, Dr Smith might have difficulty proving what the understanding was. Legally as well as ethically, what is critical is whether Mrs Daniels really understood her options and agreed to the plan Dr Smith followed Vacillating parents Suppose Mrs Daniels had insisted on the removal of only two teeth and the restoration of the others. Should Dr Smith have insisted on what she thought was the best course dentally? Here the issue is whether Mrs Daniels, as Joey’s surrogate, should have the autonomy to make choices comparable to those of competent patients like the Jehovah’s Witness who refused a blood transfusion in the previous case Vacillating parents In many cases parents are permitted to make somewhat unexpected choices that are less than what seems best; the courts do not intervene unless the surrogate’s decision is beyond reason. PROVIDER AUTONOMY The principle of autonomy requires that freely made, substantially autonomous choices be respected, even if overriding those decisions would produce more good for the decision-maker. So far we have considered the autonomy of the competent patient and of the surrogate for the incompetent patient. A third and final question raised by the principle of autonomy is whether health care professionals also have moral rights grounded in autonomy to refuse/ to provide care requested by patients. Dr Ed Van Sciver had a patient with a mandibular second molar with a large mesial, occlusal, and distal (MOD) amalgam restoration. The mesiobuccal cusp had completely broken off. The tooth was certainly restorable, and there were no endodontic complications. However, Dr Van Sciver wondered how far to go in presenting alternatives to the patient in his pursuit of an informed consent. To mention all possible alternatives sometimes seemed pointless Different options In this case, Dr Van Sciver thought the full range of choices included: 1. Cast gold crown 2. Cast gold crown with porcelain facing 3. Gold onlay 4. Replacement of the MOD amalgam, including the fractured cusp 5. Repair of the amalgam without replacement 6. Composite resin 7. Porcelain onlay 8. Extraction Importance of evidence based dentistry The crown was obviously the best choice—either with or without the porcelain facing. It was more trouble-free than was the gold onlay, and it should last longer. That was what Dr Van Sciver had been taught, what he believed, and what he would choose for himself. The problem he, like all dentists, was faced with was that he could not provide patients with objective data that would allow them to make a reasonable and informed choice. For example, there are no studies comparing crowns versus four- or five- surface amalgam restorations over periods of 5 or 10 years. Outcome data such as these are lacking in many treatment situations in dentistry. His case begins with what seems like the problem of how much information should be transmitted for consent to be adequately informed. Given that Dr. Van Sciver admits that some people would choose even those options that he finds least attractive, there is reason to believe that patients should be informed of these options. The next issue is what Dr Van Sciver would have to tell the patient about each option. Surely, the information would have to include costs, likely length of benefit, and side effects. He would also have to tell the patient that even though he does not approve of some of these options, other dentists might choose them. Referral in controversy /difficult situations On the other hand, if Dr Van Sciver can refer his patient to another competent dentist more willing to provide the controversial service and such referral does not jeopardize the patient’s welfare, then referral may be the best plan all around. Referral in controversy /difficult situations Dr Cathy Gerber, who was a graduate student in the orthodontics program of a nearby dental school. Late one Saturday, a 6-year-old boy came into the office with his father and without an appointment. The child was an occasional patient in Dr Pitts’s practice, and the family was known to be on medical assistance. Dr Pitts was busy with another patient and had two more waiting, so Dr Gerber saw the child. Her examination showed a deep caries lesion on a mandibular second primary molar accompanied by swelling of the buccal gingiva. The first permanent molar was not yet erupted. The child’s father wanted the tooth removed. Dr Gerber disagreed. She knew that when second primary molars are removed before the first permanent molars erupt, significant loss of dental arch space almost always occurs. She believed that the clinical and radiographic picture indicated that root canal treatment should be done. Dr Gerber wanted to refer the patient to a specialist, with the child to be seen on Monday, and made that suggestion to Dr Pitts One opinion versus another opinion- Root Canal Treatment Vs Extraction plus space maintainer. Dr Pitts did not believe in root canal treatment for primary teeth and thought the tooth should be removed. Furthermore, something needed to be done immediately because of the boy’s pain and infection. He also believed the parent’s wishes for the tooth to be removed needed to be considered. Dr Gerber’s concern about space loss could be managed with a space maintainer. Dr Pitts told Dr Gerber to remove the tooth. He felt quite strongly about it, both because he thought it was the right thing to do clinically and because it was his practice and he felt that he had the right to control the treatment that was conducted there. He would have done it himself except for the fact that he was so busy. Dr Gerber felt just as strongly that the tooth should not be removed and told Dr Pitts to remove the tooth if he wanted to, but she refused to do it herself ETHICAL QUESTIONS Dr Gerber is in a moral bind. Should she not be permitted to practice dentistry as she sees fit and to make the referral she thinks is best? On the other hand, her role as an associate in Dr Pitts’s practice might be seen as obligating her to practice as Dr Pitts sees fit. Does Dr Gerber have a right grounded in her own autonomy to insist on the referral, or can the patient’s father insist on the extraction? Referral in controversy /difficult situations If Dr Pitts were available to perform the extraction, transferring the patient to him might be best for everyone. On the other hand, if Dr Gerber really is convinced that extraction is not in the young patient’s best interest, she might have to ask herself whether the father’s choice is so wrong that it is intolerable. CONCLUSIONS These cases depict a head-on clash between the dentist’s autonomy to practice dentistry as he or she sees fit and the patient’s (or surrogate’s) right to choose a legal professional service that is acceptable to some competent dentists. Patients’ autonomy in and of itself does not give them the right to demand a service of a professional. E N D ADA Codes of ethics UAE code of ethics in dental practice Lecture 12 1.The Principles of Ethics The ADA Code has three main components: 1.The Principles of Ethics, are the aspirational goals of the profession. They provide guidance and offer justification for the Code of Professional Conduct and the Advisory Opinions – There are five fundamental principles that form the foundation of the ADA Code: Patient autonomy, Nonmaleficence, Beneficence, Justice and Veracity. -Principles can overlap each other as well as compete with each other for priority. More than one principle can justify a given element of the Code of Professional Conduct. Principles may at times need to be balanced against each other. The Code of Professional Conduct 2. The Code of Professional Conduct is an expression of specific types of conduct that are either required or prohibited. All elements of the Code of Professional Conduct result from resolutions that are adopted by the ADA’s House of Delegates. The Code of Professional Conduct is binding on members of the ADA, and violations may result in disciplinary action. 3.The Advisory Opinions 3.The Advisory Opinions are interpretations that apply the Code of Professional Conduct to specific fact situations. - They are adopted by the ADA’s Council on Ethics, Bylaws and Judicial Affairs to provide guidance to the membership on how the Council might interpret the Code of Professional Conduct in a disciplinary proceeding. - The ADA Code is the result of an ongoing dialogue between the dental profession and society, and as such, is subject to continuous review. - Although ethics and the law are closely related, they are not the same. Ethical obligations may– and often do –exceed legal duties. 1 –Patient Autonomy The dentist has a duty to respect the patient’s rights to self- determination and confidentiality. - This principle expresses the concept that professionals have a duty to treat the patient according to the patient’s desires, within the bounds of accepted treatment, and to protect the patient’s confidentiality. 1.A. PATIENT INVOLVEMENT. - The dentist should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions. 1.B. PATIENT RECORDS. - Dentists are obliged to safeguard the confidentiality of patient records. Dentists shall maintain patient records in a manner consistent with the protection of the welfare of the patient. Advisory opinions SUPPLYING COPIES OF RECORDS. - A dentist has the ethical obligation on request of either the patient or the patient’s new dentist to provide in accordance with applicable law, either free or for minimal cost, dental records or copies or summaries of them, including dental X-rays or copies of them, as will be beneficial for the future treatment of that patient. CONFIDENTIALITY OF PATIENT RECORDS. - The dominant theme is the protection of the confidentiality of a patient’s records. Dentists should obtain the patient’s written permission before forwarding health records which contain information of a sensitive nature, such as HIV seropositivity. Section 2 – Non Maleficence The dentist has a duty to refrain from harming the patient. - This principle expresses the concept that professionals have a duty to protect the patient from harm. - Under this principle, the dentist’s primary obligations include keeping knowledge and skills current, knowing one’s own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate. Code of professional conduct EDUCATION. - The privilege of dentists to be given professional status depends primarily in the knowledge, skill and experience with which they serve their patients and society. All dentists, therefore, have the obligation of keeping their knowledge and skill current. CONSULTATION AND REFERRAL. - Dentists shall be obliged to seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience. When patients visit or are referred to specialists or consulting dentists for consultation: 1. The specialists or consulting dentists upon completion of their care shall return the patient, unless the patient reveals a different preference. 2. The specialists shall be obliged when there is no referring dentist and upon a completion of their treatment to inform patients when there is a need for further dental care Advisory opinions SECOND OPINIONS. - A dentist who has a patient referred for a “second opinion” regarding a diagnosis or treatment plan recommended by the patient’s treating dentist should render the requested second opinion. USE OF AUXILIARY PERSONNEL. - Dentists shall be obliged to protect the health of their patients by only assigning to qualified auxiliaries those duties which can be legally delegated. Dentists shall be further obliged to prescribe and supervise the patient care provided by all auxiliary personnel working under their direction. PERSONAL IMPAIRMENT. - It is unethical for a dentist to practice while abusing controlled substances, alcohol or other chemical agents which impair the ability to practice. All dentists have an ethical obligation to urge chemically impaired colleagues to seek treatment. Advisory opinions ABILITY TO PRACTICE. - A dentist who have any disease or becomes impaired in any way that might endanger patients or dental staff shall, with consultation and advice from a qualified physician, limit the activities of practice to those areas that do not endanger patients or dental staff. POSTEXPOSURE, BLOODBORNE PATHOGENS. The dentist’s ethical obligation in the event of an exposure incident extends to providing information concerning the dentist’s own blood-borne pathogen status to the evaluating health care practitioner, if the dentist is the source individual, and to submit to testing that will assist in the evaluation of the patient Advisory opinions PATIENT ABANDONMENT. - Once a dentist has undertaken a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist. Care should be taken that the patient’s oral health is not jeopardized in the process. PERSONAL RELATIONSHIPS WITH PATIENTS. - Dentists should avoid interpersonal relationships that could impair their professional judgment or risk the possibility of misusing the confidence placed in them by a patient. Section 3 – Beneficence The dentist has a duty to promote the patient’s welfare. - This principle expresses the concept 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. Code of professional conduct COMMUNITY SERVICE. - Since dentists have an obligation to use their skills, knowledge and experience for the improvement of the dental health of the public and are encouraged to be leaders in their community, dentists in such service shall conduct themselves in such a manner as to maintain or elevate the esteem of the profession. GOVERNMENT OF A PROFESSION. - Every profession owes society the responsibility to regulate itself. Such regulation is achieved largely through the influence of the professional societies. All dentists, therefore, have the dual obligation of making themselves a part of a professional society and of observing its rules of ethics Code of professional conduct RESEARCH AND DEVELOPMENT. - Dentists have the obligation of making the results and benefits of their investigative efforts available to all when they are useful in safeguarding or promoting the health of the public. PATENTS AND COPYRIGHTS. - Patents and copyrights may be secured by dentists provided that such patents and copyrights shall not be used to restrict research or practice. ABUSE AND NEGLECT. - Dentists shall be obliged to become familiar with the signs of abuse and neglect and to report suspected cases to the proper authorities, consistent with country laws. PROFESSIONAL DEMEANOR IN THE WORKPLACE. - Dentists have the obligation to provide a workplace environment that supports respectful and collaborative relationships for all those involved in oral health care. Advisory opinions REPORTING ABUSE AND NEGLECT. - The public and the profession are best served by dentists who are familiar with identifying the signs of abuse and neglect and knowledgeable about the appropriate intervention resources for all populations. Dentists, therefore, are ethically obliged to identify and report suspected cases of abuse and neglect to the same extent as they are legally obliged to do so in the jurisdiction where they practice. Advisory opinions DISRUPTIVE BEHAVIOR IN THE WORKPLACE. – Dentists are the leaders of the oral healthcare team. As such, their behavior in the workplace is instrumental in establishing and maintaining a practice environment that supports the mutual respect, good communication, and high levels of collaboration among team members required to optimize the quality of patient care provided. 4. Principle of Justice The dentist has a duty to treat people fairly. - This principle expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues and society. - Under this principle, the dentist’s primary obligations include dealing with people justly and delivering dental care without prejudice. Codes of professional conduct PATIENT SELECTION. - Dentists shall not refuse to accept patients into their practice or deny dental service to patients because of the patient’s race, faith, color, gender, or national origin. EMERGENCY SERVICE. - Dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record. EXPERT TESTIMONY. - Dentists may provide expert testimony when that testimony is essential to a just and fair disposition of a judicial or administrative action. Advisory opinions PATIENTS WITH BLOODBORNE PATHOGENS. - A dentist has the general obligation to provide care to those in need. A decision not to provide treatment to an individual because the individual is infected with Human Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus or another blood-borne pathogen, based solely on that fact, is unethical. - Decisions regarding the type of dental treatment provided or referrals made or suggested should be made on the same basis as they are made with other patients. - As is the case with all patients, the individual dentist should determine if he or she has the need of another’s skills, knowledge, equipment or experience. The dentist should also determine, after consultation with the patient’s physician, if appropriate, if the patient’s health status would be significantly compromised by the provision of dental treatment Thus, a dentist who pays for advertising or marketing services by sharing a specified portion of the professional fees collected from prospective or actual patients with the vendor providing the advertising or marketing services is engaged in fee splitting. 5.VERACITY The dentist has a duty to communicate truthfully. - This principle expresses the