FDI World Dental Federation Dental Ethics Manual 2 PDF

I Dental Ethics Manual II An overview of ethical issues in practiced dentistry (private and public health clin- dentistry...

Dental Ethics An overview of ethical issues in dentistry This Manual is the combined result of interna- tional experts on dental ethics brought together as an FDI Working Group. By holding productive meetings and electronic discussions, this group has tapped into the diversity of its members’ perience, expertise, and knowledge of ethics, law, and philosophy in public health, private practice, urban and rural dentistry, wealthy and low- and lower-middle-income countries, traditional and modern dilemmas. Wolter Brands DDS JD PhD is dentist and co- owner of a dental practice. He was an associate professor and principal lecturer at the UMC St. Radboud and president of IDEALS, as well as edi- tor-in-chief of the Dutch Dental Journal. Currently he serves as a substitute judge in a civil court and is president of the Royal Dutch Dental Asso- ciation. His research is about the impact of law on daily dental practice. He publishes and lec- tures on this topic, both nationally and interna- tionally. Sudeshni Naidoo is emeritus professor at the University of the Western Cape. She is involved with postgraduate education and training with a focus on ethics, bioethics, and research ethics. Her CV lists more than 200 publications, including a book on ethics for the dental team. She is current president of the International Dental Ethics and Law Society. Suzette Porter is adjunct associate professor at the University of Queensland and secretary of the International Dental Ethics and Law Society. She Preface.......................................... Chapter 1: Ethics as a defining characteristic of dentistry Summary.......................................... Introduction..................................... The fiduciary relationship................................... Beneficence and nonmaleficence...................... Scarce resources and the inevitability of choices between patients.............................. Further reading.................................. Chapter 2: Introduction to dental ethics Summary.......................................... The many meanings of the term ethics............ 7 Ethics involves a critical examination................ 8 Personal opinion or reasoned argument?........ 9 A fair debate.................................... Further reading.................................. Chapter 3: The standard of care Summary.......................................... Introduction..................................... Who determines how a dentist should behave?....................................... A local or a global standard of care?................. Transparency of care, guidelines, and protocols..................................... Shared decision-making, evidence-informed decision-making, and evidence-guided decision-making............................... Individualization and the standard of care based on a long-term goal for dental treatment..................................... Real cases....................................... Further reading.................................. Chapter 4: The duty to treat Summary.......................................... Introduction..................................... Does the duty to treat depend on a prior relationship between dentist and patient?.... 22 IV Concluding remarks............................................ Further reading.................................. Chapter 7: Record-keeping Summary.......................................... Introduction..................................... What are dental records used for?.................... What constitutes a dental record?..................... Ownership of records.......................................... Access to records................................ Electronic patient records................................... Communicating with patients via email............ Retention of records............................. Use of dental records for forensic investiga- tions......................................... Checklist for dental record-keeping.................. Chapter 8: Professional behaviour Summary.......................................... Introduction..................................... Professional standards in relationships............ Understanding personal limitations.................. Fitness to practice.............................. Ethical codes of dental associations or societies..................................... Teamwork and collaboration............................. Emergency dental responsibilities..................... Concluding remarks............................................ Further reading.................................. Chapter 9: The impact of business on dentistry Summary.......................................... Introduction..................................... Conflict of interest............................. Professional versus business ethics.................. 71 Dentistry as a business....................................... Extending the scope of practice......................... 74 Concluding comment: Ethical work in progress...................................... Further reading.................................. Ethics is an integral part of the health professions. Even if dentists rarely deal with popular bioethical topics like trade in organs or assisted suicide, they face ethical challenges and must make ethical de- cisions in their everyday practice. Many of these challenges are resolved by experience. However, sometimes experience is not enough, and the dentist may need practical tools to assist with eth- ical decision-making. The biological sciences and technical compe- tences have important roles in dental education, but the degree to which ethics is taught in den- tal schools differs widely. There is, however, evi- dence that knowledge and skills in ethics will help dentists maintain pride in their work, establish a sound relationship with their patients, and sustain public trust in the profession. In 2007, the FDI World Dental Federation, rep- resenting more than 200 member organizations in more than 120 countries, published the first Dental Ethics Manual. In the words of Dr. Michèle Aerden, the then president of FDI, the manual aimed to be “an inspiration for everyone in the oral health professions and in the best interests of their patients.” It has since been a valuable re- source for dental practitioners, students, and ed- ucators alike. In 2015, the General Assembly of the FDI adopted the Policy Statement, “The Role of the FDI Chapter 1: Ethics as a defining characteristic Summary This chapter argues that dentistry cannot be de- fined in terms of its scientific foundations and clinical techniques only. Ethics, too, is a defining characteristic of dentistry. For example, the ex- pert who employs dental knowledge and skills to torture a suspected terrorist is not practicing den- tistry, let alone good dentistry. The dentist who entices a patient into undergoing orthodontic treatment without clear benefit to the patient is likewise not practicing good dentistry, nor is the dentist who routinely refuses to provide emer- gency dental care to strangers in need of such care. Introduction Both the science and practice of dentistry require dentists to make value judgments. The impor- tance of dentists examining the ethical param- eters of their practice is further underscored by the fact that patients are often vulnerable and fully dependent on dentists for their oral health- care needs. Patients must be able to trust den- tists, and the relationship between dentist and patient is generally considered to be a fiduciary one. In turn, individual dentists and the profession at large must warrant the public’s trust, which re- quires (among other things) that dentists allocate scarce oral healthcare resources, including their own time, fairly among patients in need. Case study A 12-year-old patient comes with her mother to the dentist. Her maxillary incisors are not properly aligned. The aberration is minimal and does not affect her oral functioning. Although the dentist in recent years has repeatedly counseled mother and child to improve her brushing efforts, the pa- 2 good dentistry. The same would be true for a den- tist who replaces completely healthy teeth with expensive implants, even if the patient insists on the treatment. The dentist may do so expertly, ap- plying the latest science and technology, but it is not good dentistry. In past ages, when most dentists were capable of little more than extractions, it was quite evident what was ethically required of them to be a good dentist: do not extract teeth unnecessarily and do not overcharge patients for the service rendered. Things are no longer quite as simple. Dentistry has grown into a very complex practice, and with these advancements have come new and complex ethi- cal challenges. Can dentistry be practiced without making value judgments? Critics may acknowledge the reality of these com- plexities but insist that making value judgments on behalf of patients goes beyond dentists’ exper- tise. By applying the methods of biomedical sci- ence, dentists can discover lots of facts about oral diseases. On that factual basis, effective diagnostic and treatment protocols can be developed. Den- tists can then inform patients about the various treatment options. But whether such treatments are actually of value to patients, and whether pa- tients ought to undergo them, can only be decided by the patients themselves – or so these critics would insist. But what do we mean by an effective treat- ment? Effective for what? To use this term means that there is some state of affairs that does not yet exist but which is desirable. Furthermore, the label effective implies that the treatment will not only re- alize the desired state of affairs, but also do so in a manner that is worth undergoing it. Both of these qualifiers reflect a value judgment. The state of af- fairs must be of value to somebody in order to be desirable. And somebody must find the manner in which it is realized valuable to say the treatment is worth it. Who makes these value judgments? Only patients? Contemporary dental textbooks are filled with statements about the effectiveness of diets, drugs, The fiduciary relationshi sence of disease or infirmity.” The key term in this definition is the word well-being. Clearly, this term entails a value judgment. It reflects a desirable state of being that we ought to protect and foster. The same is true for many other core concepts in dental science, such as disease, disorder, and abnormality. It is impossible to define any of these terms without making a value judgment about patients’ interests, about what ought to be, and about the norm that should be followed. In short, the very science of dentistry is always and inevi- tably based on value judgments about patients’ interests. It is therefore impossible to be a val- ue-neutral dentist. The fiduciary relationship The FDI World Dental Federation’s 2016 defini- tion of oral health emphasizes that “oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and con- vey a range of emotions through facial expres- sions with confidence and without pain, discom- fort and disease of the craniofacial complex.” The inability to speak, smile, or swallow renders a person vulnerable. When patients have a serious toothache, when they are no longer able to chew food, or when they suffer a disfiguring facial trauma, their well-being, social functioning, and occasionally even their very life may be at risk. None of these situations are a simple matter of subjective wishes or preferences, which a person is free to act on or set aside. A person with an ab- scess is not free to postpone treatment until the antibiotics are available at a reduced price; she needs the treatment. That renders the person even more vulnerable, and vulnerability in turn generates ethical obligations on the part who are not similarly vulnerable but able Patients’ vulnerability is compounded by their dependence on experts to take care of their Patients cannot treat their own abscess, their own toothache, their fractured filling; patients depend for help on dentists. What is more, patients must be able to trust their dentists. First, they must trust that when their dentists recommend certain treat- 4 nswer this question, and the answer has a across the ages. In fact, this whole dental ethics manual can be seen as an attempt to answer this question. However, two core ideas appear to have survived from the days of Hippocrates to present times. In the ancient Hippocratic Oath we already find the thesis that healthcare providers are expected to advance the patient’s good: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment.” Patients must be able to trust that dentists will always seek to advance the patient’s well-being and even give priority to the patient’s interests (as opposed to the dentist’s own interests). This obligation of healthcare pro- viders has also come to be known as the bioethical principle of beneficence. Nowadays, many ethicists are critical of this principle. They are worried about dentists doing presumably good things to patients without even asking the patients themselves. Beneficence, so these critics argue, necessarily entails paternal- ism. It is true that throughout history, healthcare providers have behaved very paternalistically. Hip- pocrates instructed his medical students never to inform patients about the true cause of their dis- ease. This tradition of silence has continued until this century, and there are still dentists who think they know what is best for the patient without ever asking the patient. However, the principle of beneficence does not itself entail paternalism. All it says is that dentists ought to act in the best interests of their patients. In fact, in most instances the principle of benefi- cence requires the dentist not to be paternalistic. It is very difficult to determine what is in a particular patient’s best interest without asking the patient. As already explained, if a dentist wants to decide what treatment is truly in the patient’s best inter- est, the dentist cannot rely on scientific facts only, but must involve the patient in the decision-mak- ing process. The principle of beneficence is paralleled by an- other principle, the roots of which go back to the Hippocratic Oath as well. The fragment from the Oath quoted above is followed by the following sentence: “I will keep them from harm Scarce resources and the inevitability Scarce resources and the inevitability of choices between patients There is a final aspect of professional dental prac- tice that we briefly review here because it is an- other source of the contemporary interest in the discipline of dental ethics. The trust of patients in dentists is not vested first and foremost in indi- vidual dentists, but in the profession of dentistry as a whole. Because of this, the profession must assure that all dentists meet basic levels of knowl- edge and skills and abide by state-of-the-art prac- tice guidelines. But knowing that all dentists are competent is unlikely to make patients trust den- tists if patients cannot gain access to the dental services they urgently need. Lack of access to oral healthcare is, of course, not a new problem in human history. It is precisely because people lacked access to competent den- tists that barbers and even quacks were able to sell their dental services to desperate clients. In some countries, large numbers of patients still have to rely on untrained practitioners to obtain urgently needed oral healthcare services because they can- not afford the services of a licensed professional or have no access to such an expert. The reality of staggering oral health disparities is widely ac- knowledged today as a major ethical challenge for the dental profession. Solving this problem is go- ing to require close cooperation among dentists, patient advocacy groups, insurance companies, policymakers, public health experts, and many other stakeholders. However, even in their own private practices, dentists are inevitably faced with challenges about balancing the interests of different and making choices among them. The quarter of an hour devoted to informing a patient about the patient’s right to refuse treatment can be spent double-checking the radiographs of another patient. A fee discount awarded to one poor patient in need of care must be balanced out by securing a small profit in the treatment of an- other patient. Note that even in an ideal world in which there is no financial scarcity, the problem of balancing different patients’ interests would not be fully 6 Glick M, Williams DM, Kleinman DV, et al. (2017). A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. Am J Or- thod Dentofacial Orthop, 151(2):229–231. Jackson SL, Vann Jr WF, Kotch JB, Pahel BT, Lee JY (2011). Impact of poor oral health on children’s school attendance and performance. Am J Pub- lic Health, 101(10):1900–1906. Ozar DT, Sokol DJ, Patthoff DE (2018). Dental Ethics at Chairside: Professional Principles and Practi- cal Applications. Washington, DC: Georgetown University Press. Chapters 1 & 5. Chapter 2: Introduction to Summary This chapter provides a basic introduction in the scholarly discipline of ethics. Dental ethics is de- fined as the critical examination of the values, rights, norms, and so on that guide the practice of dentistry. After distinguishing ethics from eti- quette and law, the important role of reasons (ver- sus opinions) in dental ethics is stressed. In the final section, three basic strategies for assuring a fair debate are reviewed: questions, explanations, and arguments. The many meanings of the term ethics In everyday life, the word ethics is used in many different ways. An entrepreneurial dentist aggres- sively marketing his practice with huge billboards all across town may be charged by his colleagues with an ethics violation. An ethics committee of the dental board may investigate the complaint. The committee may praise the dentist’s work ethic, but consider his advertising campaign unethical nevertheless. The board may next decide to hire an ethicist to consult in the process of drafting an ethics code on dental advertising. This consult- ant’s formal qualifications may include various past courses in ethics. In order to prepare for the ethical advice, the consultant may peruse a dental ethics textbook, which can be found in the ethics section of the university library. The previous paragraph contains as many as 10 diverging meanings of the noun ethics and its derivative adjective ethical. The issue could be fur- ther complicated by adding a dozen uses of the words morality and moral. In fact, in the foregoing example the word ethical could have often been replaced by the term moral, and ethics by moral- ity, which makes perfect sense because the words ethics (derived from ancient Greek) and morality 8 ily so). Whereas a pathologist studies disease (and tissues taken from diseased patients), a hygien- ist studies health (or does things to make people more healthy). To be a good dental hygienist, one must know a lot about dental health and about cleaning people’s teeth. But it is not at all neces- sary to have healthy and clean teeth oneself to be a competent dental hygienist. Likewise, an ethicist studies morality, but an ethicist is not necessarily a moral person. A pathology manual helps readers understand diseases; fortunately, it does not make the readers diseased. A dental hygiene textbook teaches stu- dents how to improve the dental health of their pa- tients; but it will not make students’ own dentition any healthier unless they decide to act in accord- ance with their newly gained knowledge and apply it to their own teeth. The same is true for dental ethics. Thus, we the authors hope this manual in- creases readers’ understanding of the moral as- pects of dental practice. Indeed, increased ethical understanding may be of help in making morally good decisions. However, it should be noted that it will be up to each reader to make the right deci- sions. It is the readers’ choice and responsibility to act in accordance with their newly gained knowl- edge of dental ethics. Ethics involves a critical examination Dental ethics critically examines the values, prin- ciples, and norms shaping the practice of den- tistry. This examination differs from the empirical research with which dentists are familiar. That is because values, principles, and norms are not facts; hence, ethical questions generally cannot be answered by collecting more facts. For example, it would be important to know that most dentists are willing to treat AIDS patients. But that empir- ical fact does not prove that dentists are morally obligated to treat AIDS patients. Most issues in dental ethics cannot be analyzed unless empirical data are available, but having those data available does not suffice to settle the ethical quandaries. The difference between an empirical study and an ethical study can also be summarized as Personal opinion or reasoned argument? Personal opinion or reasoned argument? Before we can continue our discussion of strat- egies to reach reasonable and justified ethical guidelines for the practice of dentistry, we need to tackle a challenging objection. It is extremely common nowadays to hear people say that morality is ultimately a matter of personal and hence subjective opinion, not unlike taste. In the same way that different people have different tastes, so different people have different val- ues. There is no point in arguing about matters of taste, and, likewise, there is no point in argu- ing about matters of value – or so the objection goes. So let us compare a statement about taste with a statement about values: 1. I think dark chocolate is better than white choc- olate... 2. I think you should not attempt repositioning this patient’s lower jaw... Both are statements of opinion. It makes perfect sense to continue the first statement by saying: 1.... but feel free to take a bite of the white choc- olate, if you prefer. However, it is clearly problematic to continue the second statement in a similar vein by saying: 2.... but feel free to undertake the operation way, if you prefer. Where patients’ interests, their life, are concerned, it is no longer a matter of personal opinion, taste, or style. If a dentist is convinced that the surgery proposed by a colleague will harm the patient, the dentist should not simply brush off their disagreement as a mere difference of personal opinion. Instead, the dentist should enter into a critical dialog with the colleague to de- termine what is really in the best interest of the patient. Even if the patient wants the surgery, that still does not establish persuasively that the sur- gery is objectively in the patient’s best interest. Pa- tients, too, can be mistaken about what is truly of value to them. 10 victions. In fact, there is little benefit to be gained from participants to the dialog who have never se- riously considered the ethical dilemmas being dis- cussed or who merely repeat the ideas pushed in the mass media. A person who is able to provide solid arguments in favor of a particular position is much more likely to advance the ethical debate than one who is not, provided of course that this person is also able to recognize and accept super- ior counterarguments. Genuine respect for the ideas of others is also reflected in the manner in which we carry out the debate. While it is imperative that we address ideas critically and argue about them, our criticism and counterarguments must be fair. It happens quite often that debaters, intentionally or not, resort to fallacious reasoning. For example, we may end up attacking our opponents instead of their ideas. When we use such statements as “we all know that X is not the case,” we hope to intimidate our oppo- nents such that they retreat. When characterizing our opponents as “lacking expertise,” “not know- ing what they are talking about,” or “pretty dumb,” when making fun of them or fueling their growing uneasiness, we are in effect terrorizing them in- stead of respectfully examining their views. The opposite may happen too, when we flat- ter a person (without sincerely agreeing), only to lure the person into our own camp. We may play with the emotions of others by emphasizing the sorrowful elements or by singling out the bright aspects. We may grant undue authority to the dentists in our own camp by addressing them as “Dr. Smith” and “Dr. Chang,” while referring to the opposing dental hygienists as “Mary” and “John.” All of these strategies frustrate the argumentative process and reduce the likelihood of uncovering creative innovations. There are three main strategies that partic- ipants in an ethical debate can use to move the discussion forward in a constructive and fair man- ner: ask questions, provide explanations, and con- struct arguments. Questions. The first strategy, questioning, helps to get at the truth. Unless somebody spe- cifically asks why X is true, there is the risk that everybody simply assumes X to be true, and Further reading gling with thorny ethical dilemmas for thousands of years. Philosophers have proposed different ethical theories in an attempt to make sense of the complexity of moral experiences and to help sort through vexing moral challenges. Some scholars have tried to develop an ethical theory based on mathematical principles. Others have started with human emotions. Some have ar- gued that the morality of any action depends on its consequences. Others have denied that out- comes are relevant because outcomes can be un- foreseen and completely accidental; what mat- ters instead is intent, the free-willed decision by the acting person. Still others have insisted that it is impossible for any theory of ethics to solve par- ticular clinical dilemmas, and that the most one should expect from such a theory is a general un- derstanding of how to live a morally good life as a human being. In this manual, we do not delve into ethical theory (although the reader may occasionally en- counter a brief reference to a specific ethical the- ory). Those interested in learning more about the application of different theories of ethics to the Chapter 3: The standard Summary Trust is the basis of the dentist–patient relation- ship. When patients have a long history with a dentist, trust is based on experience with that dentist. When a dentist starts a new practice after graduation from dental school, patients will come to the practice without any experience with that specific dentist. As a consequence, their coming to the practice is not based on trust in that dentist but on trust in the profession of dentistry. They trust people who call themselves “dentist” to have certain basic skills because they have graduated from dental school and been granted a license to practice by the health authorities. Introduction The recognized role of trust raises some ques- tions: Who determines how a dentist should behave? Is the explication and elaboration of ethical norms locally determined, or should they be nationally or even globally determined? What about transparency in dentistry? Should a patient automatically trust that the adhere to ethical norms? How does a patient know the manner in which these norms should be applied in the daily practice? What is the role of guidelines and protocols? In this chapter we will try to answer these ques- tions. Who determines how a dentist should behave? The hallmark of professionalism is trustworthi- ness. It is the trust in the profession as a whole that warrants patients’ trust in individual dentists. 14 Organizational aspects Relational Standard of care Technical aspects Indication The way treatment Fig 3.1 Aspects of the standard of care. body of opinion who would take a contrary view. At the same time, that does not mean that a med- ical man can obstinately and pig-headedly carry on with some old technique if it has been proved to be contrary to what is really substantially the whole of informed medical opinion.” (Bolam v Friern Hospital Management Committee 1 WLR 582) The Bolam test was used in court to establish what a dentist should do according to his relevant peers. In many countries, a standard of care sim- ilar to the Bolam standard is adopted in law or in jurisprudence, emphasizing the importance of agreement among peers. Figure 3.1 shows the as- pects of the standard. It covers technical aspects of dentistry – the indication of treatment and the way treatment is performed. It also includes or- ganizational aspects of a practice, for instance, the practice’s infection control or the duty to treat peo- ple during weekends. The third group of aspects included in the standard are the patient’s rights. From a legal point of view, there are only two options: either a particular act is in accordance with the law, or it is not. In many cases, the stan dard of care represents this border between legal and illegal in matters of oral healthcare. We need to remember, however, that even when an act is legal, it does not mean it is truly a good act, ethi- cally speaking. Suppose, for example, a local den- tal association has issued a rule that says patients A local or a global standard of care? we argued that trust in the profession is essen- tial for society. In order to get dental help, pa- tients have to trust the individual dentist as well as the profession to work in their interest and to cause no harm. If dentists, even a small minority of them, are willing to start providing treatments they themselves believe are not in the interest of the patient, the public will lose trust in the profes- sion as a whole. Change of the standard over time Because the standard of care is derived from the insights of peer dentists, the standard may change over time as new graduates enter the practice of dentistry. Some hundred years ago, patients were advised to rinse with turpentine after extraction – advice no dentist will give today. Another change in the standard of care is seen in endodontics. Decades ago, dentists used med- ication that contained arsenic. Today, in most countries, arsenic is not used. Such changes can actually happen within a short time span. Only a decade ago, most Dutch dental students, when presented with a case involving a cracked filling, wanted to replace the filling. Today, they do not consider immediate replacement necessary (sur- vey research performed by W. Brands). And not only has the indication for a filling changed over time, but also the way the cavity is prepared. For a long time (since 1891), cavities were prepared ac- cording to Black’s “extension for prevention” cept, with sound tooth material being removed. This concept has now been set aside for a more preservative approach, both for the use of resin fillings and for amalgam fillings (Osborne 1998). As the practice of dentistry continues to change over the years, so does the standard of care. A local or a global standard of care? The way in which the standard of care is inter- preted differs from country to country, and even within a country. For example, some countries as- sess the standard as a “national standard of care,” while other countries employ the “locality rule.” If 16 Laws Protocols Codes of conduct Transpcancy Standard Scientific articles of care Jurisprudence Fig 3.2 The sources of the standard of care and transparency of care. jurisprudence are by definition limited to a certain country (or even area of a country) they will not lead to a global uniform standard of care. More- over, such legal information is not always easy to access, and dentists are rarely interested in legal matters. Research has shown, for instance, that Dutch dentists know little about the legal rules that pertain to their dental practice. The third and most important source of the standard of care is dental science. The indication, and the best way to perform treatment, should be based on scientific evidence. The leading opinion today is that dentistry should be evidence-based. Since scientific findings are supposed to be true anywhere in the world, in theory this could lead to a global standard of care. However, there are some challenges. The first challenge is the accessibility of research. There are huge databases like PubMed, but researchers can only find information there if they know what they are looking for. In addition, although there is a tendency for open access, many hard-core research journals are only accessible in full text at high costs. Another challenge is the scientific articles themselves. Nowadays one must know quite a lot about statistics to evaluate published research. Another challenge when evaluating re- search may be ties between the researchers and suppliers, such as suppliers of a filling material. Shared decision-making, evidence-informed Before protocol Overtreatment No shared decision Bandwidth of standard Shared decision Undertreatment No shared decision Fig 3.3 A protocol limits the bandwidth to mere advice for their members. The most im- portant question concerning guidelines and pro- tocols is whether a clarification of the standard of care is always beneficial to dental patients and third parties. The standard of care and circumstances Guidelines and protocols are adapted to normal circumstances – an averagely skilled, prudent dentist in an adequately equipped prac- tice. But what if the circumstances are not nor- mal? In that case, we should go back to the defi- nition of the standard: What would be done by the reasonably prudent dentist in these abnor- mal circumstances? It is important to keep this standard in mind when a patient cannot come to the practice because of illness. In this case, the first question that arises is: Did the patient do everything that could be expected to come to the practice? The second question is: Are there other dentists who are better equipped to perform treatment at the patient’s home? Let us assume the answers to these questions show that a den- tist has the choice between leaving a patient who cannot come to the practice for good reasons, or performing treatment that is of less quality than under normal circumstances. In the latter case, the standard of care is not the care a reasona- 18 standard of care becomes clearer, so there should be less confusion. But paradoxically, the development of proto- cols can also have disadvantages for patients. To explain this point, it is necessary to return to an earlier conclusion: that a dentist can only offer treatment that is within the standard of care (with the exception of treatment that, while meeting that standard, would not be beneficial to ticular patient). Consequently, a patient can only request treatments that are within the standard of care. The broader the space within the profes- sional standard between overtreatment and un- dertreatment, the more room there is for dentists to meet the diverging requests of their patients while still abiding by the standard of care. Consider, for example, a patient who wants a perfectly functional but discolored filling removed. While most of the dentist’s peers might consider replacement of such a filling improper, the broad leeway in the standard of care could allow the pa- tient’s own dentist to grant the patient’s wish. But if a much stricter protocol with less leeway is is- sued, there will be less room for negotiations be- tween the individual dentist and his/her patient. Thus, reducing uncertainty in the standard of care may also cause limitation of choices. There may be another solution: evidence-in- formed and evidence-guided decision-making. In the first concept, a dentist informs the patient about the evidence for certain treatment. But the dentist and patient may choose other treat- ment than the relevant evidence-based guide- line or protocol prescribes, if this is what the pa- tient requests. Gitterman and Knight proposed a similar solution: evidence-guided practice. Evi- dence-guided practice incorporates research find- ings, theoretical constructs, and a repertoire of professional competencies and skills consistent with the profession’s values and ethics and the in- dividual social worker’s distinctive style (Gitterman and Knight 2013). In many countries, dentists and patients are not allowed to deviate from the standard, and den- tists will face legal problems when they and their patients choose treatment outside the standard of care, even if the patient is adequately informed, Real cases In other words, in this concept, dentist and pa- tient agree about a long-term goal of the treat- ment. This can vary from pain-freeness with the acceptance of a denture within a period to the long-term preservation of natural teeth at all costs. As a consequence, a guideline or a protocol is, in this concept, only applicable when it has the same long-term goal as the dentist and the patient (Brands and van der Ven 2015). In theory cept can be used in countries with strict and bind- ing standards of care when several conditions are met. The applicable guideline should mention what treatment is advised, given a certain goal. The den- tist should adequately inform the patient. tient should be able to weigh his interest in the long term. There must be agreement between dentist and patient about the long-term goal of treatment (this goal should be evaluated after some years). And, last but not least, the goal and the evaluation should be recorded in the patient’s files. Real cases 1. A dentist extracts a maxillary molar of a col- league. The molar breaks, and the extraction causes a perforation of the antrum. The dentist and his patient (also a dentist) agree to leave things as they are and make a bridge to replace the extracted molar. After the root of the ex- tracted molar, which was left in place, causes an inflammation, the patient brings the case before a dental board. The dentist argues that he is not to blame as the patient, who was a dentist himself, agreed to the treatment plan. How should the board respond to this com- plaint? 2. A patient visits a dentist for a check-up. The den- tist finds periodontic problems. As the relevant The Summary One of the main interests of patients is to get help w I Manual II practiced dentistry (private and public health clin- ics) in rural/remote Queensland and Papua New Guinea before gaining an MBA and PhD, lecturing in both dentistry and management. Before retir- ing she was coordinator of community dentistry and director of clinical placements at UQ School of Dentistry. ex- Michael Sereny DDS is co-owner of a dental practice in Hannover, Germany. He was assistant professor at the Medical University of Hannover, president of the dental chamber in Lower Saxony, and board member of the German Dental Associ- ation. He was elected chair of FDI Dental Practice Committee in 2016. Ward van Dijk is owner of a dental practice in Amstelveen, the Netherlands. He was member of the national board of the Royal Dutch Dental Asso- ciation and member, then chair of the FDI Dental Practice Committee. He is commercial manager of a billing company for dentists in the Netherlands and lectures on dental management. Jos Welie studied medicine, philosophy, and law and is currently a Professor of Health Care Ethics at Creighton University (Omaha, USA). He is the Founding Secretary of the International Den- tal Ethics and Law Society, taught dental ethics for some 15 years, and published extensively on topics in dental ethics, including an edited volume entitled Justice in Oral Health Care – Ethical and Edu- cational Perspectives. This Manual is a publication of FDI World Dental Federation. Its contents do not necessarily reflect the policies of the FDI, except where this is clearly and explicitly indicated. III Contents ........................ V The duty to treat: Patients of record versus prior unknown patients................................. 22 Requested treatment and the duty to treat.................................................................. 23 ..................... 1 Duty to treat and the characteristics of the ..................... 1 patient who seeks help.................................. 24 3 Is a dentist obliged to accept a patient as a 3 patient of record?........................................... 26 Terminating the relationship with a patient 5 of record.......................................................... 26 .................. 5 Terminating the dentist–patient relationship because of the patient’s conduct.................. 27 Terminating the dentist–patient relationship ..................... 7 because the dentist plans to limit his practice............................................................. 27 Questions.............................................................. 27 Further reading.................................................... 28 ..................... 9 .................. 11 Chapter 5: Principle of respect for patient autonomy Summary............................................................... 29 ..................... 13 Introduction.......................................................... 29 ..................... 13 Respect for autonomy: Consent........................ 30 Patient decision-making incompetence............ 31 ..................... 13 Decision-making for children and 15 incompetent adult patients........................... 32 Information is never value-neutral and can ..................... 16 be harmful....................................................... 35 How much information is enough?................... 36 Limits to the right to information...................... 37 ............... 17 Recapitulation: Toward a respectful relationship...................................................... 38 Further reading.................................................... 38 .................... 18 ....................... 19 Chapter 6: Confidentiality and privacy .................. 19 Summary............................................................... 39 Introduction.......................................................... 39 Why is confidentiality important?...................... 39 ..................... 21 What is confidential and what is not?............... 40 ..................... 21 Duty of confidence............................................... 40 Data protection.................................................... 42 Privacy, confidentiality, and security................. 42 Contents 43 Chapter 10: Access to care .................. 44 Summary............................................................... 79 Introduction.......................................................... 79 Public health bioethics........................................ 79 ..................... 45 Global burden of oral diseases.......................... 80 ..................... 45 Ethical considerations in improving access to 45 care: What kind of oral healthcare do we 46 owe?.................................................................. 81 47 Distributive justice............................................... 82 ................. 47 Social inequities and access to oral health....... 82 48 Financial considerations and pro bono care.... 83 48 Ethics training for dental professionals............ 84 ............... 49 Some strategies.................................................... 84 Concluding remarks............................................ 85 ......................... 50 Further reading.................................................... 87 50 Chapter 11: Research Summary............................................................... 89 ..................... 53 Introduction.......................................................... 89 ..................... 53 A historical perspective....................................... 89 53 Research guidance documents.......................... 91 55 Concluding remarks............................................ 98 .................. 57 Further reading.................................................... 99 ...................... 59 Chapter 12: Culture, altruism, and the 59 environment 63 Summary............................................................... 101 65 Introduction.......................................................... 101 .................. 65 Culture................................................................... 101 Altruism................................................................. 104 Environment: Impact of dentistry on environ- ..................... 67 mental sustainability...................................... 108 ..................... 67 Further reading.................................................... 109 .................. 67 Appendix: A step-wise approach to ethical 72 decision-making Case study............................................................. 111 Further reading.................................................... 114 ..................... 77 .................. 77 Glossary................................................................ 115 V Preface in Dental Ethics.” A recommendation was included that a new, updated manual be produced. In prep- aration for the updated manual, an international team of experts drafted the “International Prin- ciples of Ethics for the Dental Profession,” which were adopted in 2016 by the FDI’s council as the basis for the new publication. This Manual is not intended to be a comprehen- sive text on dental ethics, but is designed to intro- duce the reader to current and emerging ethical topics that arise in the practice of dentistry. It has been written in such a way that the reader can di- rectly access an individual chapter of interest. Each chapter illustrates theoretical content with short cases, and an appendix provides an example of how to analyze an ethical dilemma systematically. Chapters were written by different authors, and terminology may differ slightly throughout the book. Moreover, some terms may differ in their meaning from one author to another. Clarification of the terminology used in this manual is provided in a glossary. Suggestions for further reading are included at the end of each chapter. The reader is reminded that this Manual has been written to be of relevance to an international readership. Therefore, it does not address national codes of ethics or laws of individual jurisdictions, and does not replace the need for seeking ethical or legal advice at a local level. 1 of dentistry tient’s oral hygiene remains poor. The girl wants braces now, so her teeth will look perfect by the time she goes to high school at age 14. The mother supports her daughter’s wish. But the dentist is concerned, because the poor hygiene is a contra- indication for braces. This case shows how dentistry inevitably evokes ethical questions. For example: Would a refusal to commence the orthodontic treatment be justified, and why? How should medical bene- fits and harms be weighed against other aspects of patient well-being, such as good looks and teen confidence? What actually counts as a medical benefit? Do individual dentists or the profession at large have any responsibility to counter the mod- ern consumer culture, which readily capitalizes on teen peer pressure? And then there is the issue of decision-making authority. Who should make the treatment decisions: Dentist, patient, parent? How much weight should the dentist assign to the wishes of the 12-year-old girl? Does it matter that mom agrees? Some will argue that the answers to these questions will have to come from law, politics, re- ligion, market forces, social convention, or some other moral source outside the practice of den- tistry. This chapter adopts the opposite, inter- nalist view: the values, principles, and ethos that guide the practice of dentistry are internal to the practice of dentistry itself. In order to practice good dentistry, it does not suffice to stay abreast of recent developments in the field of dental sci- ence, nor does it suffice to continuously improve one’s technical competencies. Both of these are necessary to practice good dentistry, but not suf- ficient. It is equally necessary to adhere to the ethical standards that define the practice of den- tistry. For example, dentists who use their expertise to torture suspected terrorists are not practicing good dentistry; in fact, one could argue that their actions cannot even be called dentistry, let alone Chapter 1: Ethics as a defining characteristic of dentistry surgeries, and other therapies. Apparently, the dental scientists writing these chapters presume certain values. They take for granted that most pa- tients share the scientists’ own values in matters of oral well-being and health. This allows dental scientists to make statements about the effective- ness of all kinds of dental treatments without ever asking what individual patients really desire and want to undergo. For example, a clinician may tell the patient: “Surgery is the most effective treatment for this oral cancer.” This statement would not make any sense if the clinician saying it also claims never to make any value judgments on behalf of patients, for it reflects a particular view about what is truly a desirable state of affairs for this patient (and hence, how that goal can best be achieved). In calling surgery “the most effective treatment,” the clinician expresses the view that complete remis- sion of the tumor is a desirable and worthwhile end result. What if the patient expresses a worry about the postoperative scar and prefers radiotherapy? This response calls into question the clinician’s value judgment, and surgery therefore may not be the most effective, or even an effective treatment. In fact, it is quite common for patients not to seek the kind of optimal oral health that their dentists and indeed dental science itself assumes to be the goal of oral healthcare. Instead, patients may have other goals when seeking oral healthcare, such as freedom from pain at the lowest cost available. A treatment that may be effective at optimizing oral health may not be at all effective at achieving free- dom from pain at the lowest cost. We thus find that a simple and seemingly val- ue-neutral statement about an effective treatment necessarily entails a value judgment about what is in a patient’s best interests. And what is true about the concept of effectiveness is equally true about other basic scientific terms. Take the concept of health. It does not simply describe a particular physiological state of being. Instead, it suggests a state of being that is desirable and valued. As early as 1948, the World Health Organization (WHO) de- fined health as “a state of complete, physical, men- tal, and social well-being and not merely the ab- 3 ments, those recommendations are based on the patient’s diagnosed needs and not the dentist’s own interests. Second, patients must trust that their dentists are actually competent to provide the indicated treatments. The relationship be- tween patient and dentist is therefore also charac- terized as a fiduciary relationship, or a relationship of trust. Warranting patients’ trust in the profes- sion of dentistry is an important ethical challenge for each individual dentist. Some critics may object that most dental pa- tients are not truly vulnerable and dependent in the same way that the child with a broken bone or the woman with breast cancer are. Dental pa- tients’ lives are rarely at risk, and with regular preventive care, even raging abscesses and de- bilitating pain have become rare. Moreover, a continually growing number of dental interven- tions have purely cosmetic aims and are hence elective. It is doubtful that this criticism – that most den- tal patients are not truly vulnerable – is empirically correct, particularly when interpreted globally. Even in the USA, which spends more of its gross national product on healthcare than any other country, children lose more days of school to car- ies than to any other disease. But the criticism does point to yet another important ethical chal- lenge. To the extent that interventions provided by dentists are purely elective or aim to reach a nonhealth goal (such as beauty), the relationship changes as well from a fiduciary relationship be- tween a healthcare provider and a patient, to a contractual relationship between a businessper- son and a client. In turn, that change generates a different set of ethical principles and norms to which the dentist must adhere. We discuss this is- sue in greater detail in Chapter 9. of those to care. Beneficence and nonmaleficence needs. We have argued that the core element of the fi- duciary relationship between dentists and pa- tients is trust. Patients must be able to trust their dentists. But exactly what is it that patients may trust dentists to do or not to do? It is not easy to Chapter 1: Ethics as a defining characteristic of dentistry evolved tice.” Though mentioned secondarily, this princi- ple is probably even more pivotal, as is expressed in the ancient rule: Primum non nocere – first and foremost, do no harm! The historical reasons for such a drastic warn- ing are evident. Much of ancient, much of medie- val, and indeed much of pre-19th century medi- cine was quite risky to the patient. One’s chances of being healed by a physician were not much greater than one’s chances of being healed by na- ture. Moreover, one’s chances of being harmed by the physician’s interventions were considera- ble. No wonder physicians were taught to back off if they were not sure: In dubio (dubiis), abstine! – when in doubt(s), abstain! With the advent of modern, scientific medicine, patients’ chances have improved tremendously, and most healthcare providers have more or less forgotten the warning to do no harm first and foremost. However, this warning continues to be very important, as expressed in the contemporary bioethical principle of nonmaleficence. It would obviously be a violation of the principle of nonma- leficence to kiss a sedated patient or intentionally infect one’s patient with HIV. However, less egre- gious practices, such as overtreatment of patients or performing dental interventions requested by the patient yet known to be ineffective or harmful, would violate this principle as well. Even well-intentioned dentists who carefully guard against overtreating patients are likely to harm their patients occasionally. There is ample evidence that dentists make mistakes, or treat- ments have unexpected harmful outcomes, in- cluding death. Almost every dental intervention, whether diagnostic, preventive, therapeutic, or experimental, poses certain risks to the patient and involves some harm. We tend to call those risks side effects, but they are no less real. When- ever we risk inflicting more harm than good on the patient, we must abstain. At the very least, we should pause to re-examine the situation and the proposed interventions and discuss these matters with the patient. After all, it is the patient who will be the one to enjoy the benefits, as well as un- dergo the harms. and injus- of choices between patients 5 solved. The clearest example of such a balancing problem occurs when maintaining the confiden- tiality of one patient may result in harm to other patients. Such a conflict may arise when a patient is suffering from a highly contagious disease, such that the patient poses a threat to the health of oth- ers. Yet protecting those others may necessitate violating the patient’s confidentiality. Breaching confidentiality in turn may lead the contagious pa- tient to become distrustful of dentists and shun them altogether, resulting in a lack of treatment and an ever-worsening condition. Simple, everyday routines involve such conflicts and demand choices by the dentist. Dentists must manage their time commitments to different pa- tients; they have to decide who will get the free drug samples and who will not; they must assess when a patient’s need is so urgent that other patients may be left waiting; they must choose how many indigent patients the practice can accommodate. Conflicts, small and large, between one patient’s in- terests and those of another, are inevitable in day- to-day dental care. We will discuss these challenges in greater detail in subsequent chapters. These are not the only conflicts of interests that routinely surface in the practice of everyday den- tistry. Dentists bear responsibilities not only to pa- tients but also to the people working for and with the dentist, be they employees, fellow dentists, or other health professionals. Dentists must accept responsibility for these inevitable balancing acts. Elsewhere in this manual we will discuss the spe- cific moral challenges that arise out of a dentist’s membership in a healthcare team and, at an even greater scale, the profession of dentistry. patients This chapter was written by Jos V. M. Welie no longer Further reading Chambers DW (2011). Ethics fundamentals. J Am Coll Dent, 78(3):41–46. Da Costa Serra M, Fernandes CMS (2016). Den- tal ethics. In: ten Have H (ed): Encyclopedia of Global Bioethics, pp. 829–836. Cham, Switzer- land: Springer International Publishing. Chapter 1: Ethics as a defining characteristic of dentistry Pellegrino ED (2001). The internal morality of clin- ical medicine: a paradigm for the ethics of the helping and healing professions. J Med Philoso- phy, 26(6):559–579. World Health Organization (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Confer- ence, New York, June 19–22, 1946; signed on July 22, 1946 by the representatives of 61 states (Official Records of the World Health Organiza- tion, no. 2, p. 100) and entered into force on April 7, 1948. Available at: http://www.who.int/ governance/eb/who_constitution_en.pdf 7 dental ethics (derived from Latin) literally mean the same, as do the adjectives ethical and moral. Yet on closer inspection there are some signif- icant differences between those meanings. If we question a dentist’s ethics or charge the dentist with an ethics violation, we contend that the den- tist has behaved in ways that are unjust, wrong, unfair, blameworthy, or irresponsible. But if we call in an ethicist who has completed various eth- ics courses and reads books on ethics, we are examining a behaviour. In this chapter, the term ethics is reserved for the scholarly discipline that studies behaviours. Exactly what kind of behaviours does the dis- cipline of ethics study? We do not expect a dental ethics committee or dental ethics consultant to deal with the technical aspects of dental practice, nor with the scientific, administrative, economic, or legal aspects. Ethics is concerned with the moral aspect of human behaviours. An ethical study of human behaviour is always e-valu(e)-ative. An ethicist looks at the values that are expressed by certain behaviours, the values that affect human behaviour, or those that are affected by human behaviour. Members of healthcare ethics commit- tees will ask such questions as: “Was it justifiable what Dr. Smith did?” “Is our clinic treating patients fairly, and are we respecting their rights?” “Would it be wrong to breach confidentiality in this par- ticular case?” In this chapter, the term morality is reserved for all these phenomena taken together: values, justice, fairness, rights, and so on – in short, the normative structure of certain practices and of human life in general. Ethics studies morality. Let’s further clarify this distinction by draw- ing some analogies. Pathology is the study of diseases, disorders, handicaps, and symptoms (which we may collectively call maladies). Unfor- tunately, we quite commonly say that Mr. A suf- fers from this or that pathology, when we actually mean this or that disease. After all, it is clear that a pathologist is not diseased (at least not necessar- Chapter 2: Introduction to dental ethics the difference between a descriptive and a pre- scriptive approach. Whenever a scholar adopts a descriptive approach, the aim is to adequately describe the state of affairs at any given place and any given moment in history. The descriptive scholar wants to know how things were, are, or will be. On the other hand, a scholar adopting a prescriptive approach wants to know how things ought to be. If we cannot find out how things ought to be by collecting more data on how things are, how can we find out? One answer is to turn to customs: we ought to treat patients this way and not that way because that is how we have always done it. This answer is reasonable. There is usually wisdom in established traditions. Both the ancient Greek original of the word ethical and the Latin original of the word moral refer to customary or appropri- ate behaviour in society. Many behavioural rules that guide the behaviour of dentists are a matter of custom. Dress codes are a good example. Another answer is to turn to law. That too makes sense, for the very purpose of laws is to tell people what they ought to do and not do. And again, each country today has issued a variety of laws instruct- ing dentists on how they ought to practice. So, what is different about customs and law on the one hand, and ethics on the other? In this chapter, the difference is explained in terms of reasonableness. Customs and laws are binding, even if the reasons for the specific obligations are not (or are no longer) evident. Whether we walk on the left side of the sidewalk or on the right doesn’t really matter, as long as we all abide by the same custom. If, on the other hand, the reasons for a moral obligation are not clear, the moral obligation itself ceases. Adultery is morally wrong, not because tra- dition, parliament, God, or some other authority prohibited it. Rather, it is morally wrong because a solemn promise is breached. Conversely, since we can no longer justify the longstanding prohibition against informing patients of their diagnosis, that moral prohibition has ceased to exist. The exam- ples given here show that the process of critical reasoning is essential to the discipline of dental ethics. 9 Note that in an ethical dialog, the question is not who is right, but what is right and why. It is the ideas and arguments that count, not the people voicing them. The advocate of repositioning the patient’s lower jaw must explain why it is in the patient’s best interest to undertake the surgery. The opponent must challenge that view, provid- ing arguments against the surgery. Out of that confluence of different explanations and argu- ments, hopefully a well-founded viewpoint arises about this particular patient’s interests, as well as a decision about the best clinical course of action in view of those interests. It is irrelevant whether this final proposal turns out to be exactly what one dentist believed from the very start of the dialog, whether it is somewhere in the middle of different starting beliefs, or whether it is surpris- ingly innovative. Ethical debates are founded on the conviction that a novel, enriched, and morally sound view- point can arise out of the confluence of many dif- ferent perspectives on the case. Such a high ideal assumes that the ethical debate is conducted with the greatest possible degree of care and rigor. The various ideas and insights must be laid out, clarified, analyzed, examined, criticized, refined, combined, re-examined, and so forth until a properly argued conclusion is reached. To be successful, this argu- mentative process requires that the participants to the dialog be able and willing to debate fairly. any- A fair debate and well-being Fairness in an ethical dialog first and foremost implies genuine respect for ideas, one’s own as well as those of others. Genuine respect is not a matter of polite tolerance. Genuine respect en- tails interest and concern, a willingness to listen to new ideas, to carefully consider them, and to critically test and appraise them. Genuine respect may lead one to exchange one’s opinions for new and superior insights, adjust one’s own opinions, or defend them against alternative ideas that fail this critical test. There is nothing wrong with entering an ethi- cal dialog with strong and principled moral con- Chapter 2: Introduction to dental ethics so the truth of X is never carefully examined. The purpose of persistent questioning is not to cast doubt on everything that is being said and create confusion and uncertainty, but to deter- mine what exactly the truth is. Explanations. The second strategy is to ex- plain one’s views in great detail. Without such laying out of ideas, other participants to the debate may not fully grasp the intentions of the speaker. This is even more important when participants to the debate represent different professional disciplines, cultures, national her- itages, or religious denominati.ons. Explana- tions force the speaker to be self-critical and al- low for greater understanding among the other debaters. Arguments. Arguments are the most important elements of an ethical dialog. In the English lan- guage, the word argument evokes associations with aggression and even fights (as in the state- ments: “I got into an argument with my brother” or “John is an argumentative fellow”). But “to ar- gue” literally means to clarify. Indeed, the pur- pose of an argument is to make one’s idea so clear that any reasonable listener must agree. If a mathematician clarifies with a series of ge- ometrical maneuvers that a2 + b2 = c2, the at- tentive observer will conclude that a2 + b2 does indeed equal c2. Likewise, if we grant the thesis that all competent patients must give explicit in- formed consent prior to nonemergency dental treatment and we establish that John Smith is competent, and that the proposed reposition- ing of the lower jaw is not an emergency treat- ment, then it follows logically that John Smith must explicitly consent to the repositioning. And what if John is not competent? Based on the in- formation provided so far, we cannot logically conclude whether he must consent explicitly. So, a new question arises: What decision-mak- ing rights do incompetent patients have? This is how a fair debate in ethics proceeds. Then again, some ethical dilemmas are so com- plicated that even a fair debate among open- minded participants does not yield an acceptable resolution. Indeed, humankind has been strug- 11 analysis of ethical topics in dental practice should consult one of the many textbooks of dental ethics currently available. This chapter was written by Jos V. M. Welie Further reading Morrow D (2017). Moral Reasoning: A Text and Reader on Ethics and Contemporary Moral Issues. Part I: Reasoning About Moral and Non-Moral Is- sues. Oxford, UK: Oxford University Press. Richardson HS (2014). Moral reasoning. In: Zalta EN (ed): The Stanford Encyclopedia of Philoso- phy (Winter 2014 Edition). Available at: https:// plato.stanford.edu/entries/reasoning-moral/ Rule JT, Veatch RM (2004). Ethical Questions in Dentistry, 2nd ed. Chapter 3: Basic ethical the- ory, pp. 69–86. Berlin, Germany: Quintessence Publishing. Slote MA (2004). Ethics: I. Task of ethics. In: Post, SG (ed): Encyclopedia of Bioethics, pp. 795–802. New York, NY: Macmillan Reference USA. 13 of care Conversely, it is only when each individual dentist practices in accordance with professional norms that the public’s trust in the profession as a whole can be sustained. If every dentist did whatever he or she personally deemed beneficent for the pa- tient, there would be a high probability of patients getting different treatment plans from different dentists. In fact, it only takes one journalist to com- pare a few dozen dentists and find that they all prescribe different treatments, to bring damage to the public’s trust in the profession of dentistry. Reader’s Digest, one of the most widely read magazines in the United States, published an issue in 1997 with the damnatory title on the cover, “How Dentists Rip Us Off.” The cover article showed that price estimates for treatment of a particular prob- lem for one dental patient ranged from $500 to $30,000. To prevent such disparities in treatment plans, the profession should inform both individ- ual dentists and the public at large of the accepted standard of care for dentistry. In general, the standard of care in dentistry is defined as what would be done by the reasonably prudent dentist in the same circumstances. This criterion was first used in an English civil law case and is called the Bolam test. dentist will The Bolam case Mr. Bolam was wounded during electroconvulsive therapy, and he sued the hospital. In order to de- termine whether or not the hospital was negligent, the judge instructed the jury: “I myself would prefer to put it this way, that he is not guilty of negligence if he has acted in accord- ance with a practice accepted as proper by a re- sponsible body of medical men skilled in that par- ticular art. I do not think there is much difference in sense. It is just a different way of expressing the same thought. Putting it the other way round, a man is not negligent if he is acting in accordance with such a practice, merely because there is a Chapter 3: The standard of care who have had an accident should be seen during aspects a weekend. The association has issued no rule re- garding any other emergency action. This implies that a dentist is not obligated to help patients with a toothache. Nevertheless, one could argue that the ethical principle of beneficence obliges a den- tist also to see people with a simple toothache during the weekends. What if a patient wants treatment that is against the standard of care? is performed What if a patient asks the dentist for treatment that is against the standard of care? The answer to this question firstly depends on the local law. In many countries, the law forbids the dentist to di- gress from the standard of care, unless following the standard is harmful to the patient. If the den- tist believes it is, the dentist will have to provide scientifically and clinically sound reasons to prove that following the standard is not in the best in- terest of this specific patient. In most jurisdictions, the mere wish of the patient is not a valid reason for deviating from the standard. Now, some may object that a well-informed pa- tient knows best what is good for him, so the den- tist should follow the request of the patient. But this objection is itself questionable. Firstly, many patients do not know what is good for them in the long run, and so they have to be protected against themselves. For instance, a pa- tient who is very afraid of the dentist and requests to have his perfect teeth removed so he does not have to face the dentist ever again, may be right in the short term, but eventually he will most likely regret his request. Another example is the patient whose front teeth hurt so much that he asks the dentist to remove them to get rid of the pain in- stead of agreeing to a conservative treatment. Secondly, the patient is not the only one with interests. The dentist, for instance, cannot be forced to perform a treatment that will harm the patient. Other parties involved may be insurers. It is unreasonable to expect an insurance company to pay for treatment that will harm the patient. And then there is the dental profession as a whole. It, too, has an interest. In the introduction 15 the locality rule is used, the dentist’s interventions are evaluated according to the standards of the community. It is important to bear in mind that both of these standards focus on the dentists and their geographically determined habits. Neither standard is well-equipped to address the ever-in- creasing geographical movements of patients who may come to dentists with culturally motivated re- quests. In several parts of Africa, for instance, it is es- thetically desirable to grind the front teeth so they are pointed. In other countries, front teeth are removed altogether. At first sight, it may seem evident that extracting healthy teeth solely to meet culturally defined ideas of beauty is harm- ful. Then again, it is not uncommon for orthodon- tists in Western countries to remove sound pre- molars when the ultimate goal of that intervention is purely esthetic, and yet those extractions are within the standard of care in these Western coun- tries. In short, the standard of care appears to re- flect not only prevailing educational and technical levels in the region, but also the dominant values about health and beauty. We will discuss this topic in Chapter 12. Though there are certain local elements in the standard of care, there is a tendency to move away from locally determined standards of care toward the gradual adoption of standards of care that are more global. To understand this tendency, the sources of the standard need to be examined. con- Standards of care and evidence-based dentistry Dentists are trained in different schools in differ- ent countries and in different times. They have gained different experiences treating different pa- tients. Therefore, the odds of deriving a uniform standard of care from the personal insights of a group of individual dentists are low. What other sources are available upon which to base stand- ards of care? A second source for the standard of care is the existing laws and the decisions reached by local dental boards and disciplinary courts about the practices of individual dentists. As laws and Chapter 3: The standard of care This will be discussed in detail in Chapter 9. The Guidelines conclusion is that there is a tendency to embrace evidence-based dentistry, but it is very difficult for a dentist, let alone for a patient, to weigh up the evidence. The standard of care is like an iceberg: most of it is not visible for dentist, patients, or third parties. Transparency of care, guidelines, and protocols Individual prefer- ences of dentist Experience of dentist The standard of care is not only a standard for dentists, to help them make the best choice for a patient. It also serves as an aid for patients, to judge the treatment their dentist proposes. In this way, the standard of care is an instrument to serve the autonomy of the patient. The standard is also used as an instrument to help the dentist account for his choices and work. By applying this standard of care, third parties can judge the work of a den- tist. To serve these different objectives, the stand- ard should be transparent, easily accessible, and understandable, not only for dentists but also for patients and third parties (see Fig 3.2). To clarify the standard and make it more trans- parent, relevant organizations develop guidelines and protocols. When these guidelines concern organizational or patient rights, they are usually based on local laws, local jurisprudence, and the opinion of expert dentists or members of local dental associations. When guidelines or protocols concern the indication of treatment and the way treatment is performed, they are usually based on evidence or derived from scientific articles. Besides evidence, authors of clinical guidelines consider the opinions of practicing experts. Often consumer or patient organizations are involved in the development of guidelines. However, even when there are clear guidelines, some challenges remain. Is the organization that made the guidelines considered relevant by den- tists and hence a trusted authority? Are the guide- lines and protocols available to all dentists, to the public, and to third parties? Occasionally, organiza- tions make them available only to their members. By doing so they limit the scope of their guidelines decision-making, and evidence-guided decision-making17 After protocol Overtreatment No shared decision Bandwidth of standard Shared decision Undertreatment No shared decision of the standard and thus shared decision-making. bly prudent dentist should deliver in his or her well-equipped practice – but what a reasonably capable dentist should do in these specific cir- cumstances. Shared decision-making, evidence- informed decision-making, and evidence-guided decision-making reasonably Clarification of the standard of care can prevent some unexplained differences between dentists when it comes to the indication of treatment. Ear- lier we saw that these differences confuse the pub- lic, and that the press then concludes that dentists cheat their patient, thus undermining the trust of the public in the profession. Figure 3.3 shows what happens when the standard of care concerning the replacement of a filling is clarified by a protocol. Before the imple- mentation of the protocol, the standard has a cer- tain validity. If dentists replace fillings too quickly, they overtreat, and if they replace fillings too late, they undertreat patients. As the standard of care is rather vague, there is a broad zone in which one dentist would replace a filling while the other would rather wait, and yet both practice within the standard of care. This may lead to confusion of the public. After implementing the protocol, the Chapter 3: The standard of care perfectly capable of judging what is good for him, and the choice is recorded in the patient’s records. As a result, evidence-informed or evidence-guided decision-making is only allowed within the standard of care. As we saw earlier, the smaller the leeway in the standard of care, the less room for evidence- informed or evidence-guided decision-making. the par- Individualization and the standard of care based on a long-term goal for dental treatment As noted earlier, in countries with a rigid, protocol- ized standard of care, shared decision-making is only possible within the strict and narrow bounda- ries of guidelines and protocols. Perhaps there is, even in countries with a binding and strict stand- ard of care, a possibility to have more space for shared decision-making. To understand why such space actually exists, we need to revisit the very foundations of the standard of care, that is, the obligation to benefit the patient. Though guidelines or protocols do not mention their goal explicitly, most of the time the goal of the guideline is to reach an optimal condition of health. In medicine, this goal is evident and enjoys widespread support, since good health is valued highly by the vast majority of people, and in order to attain good health, patients are often willing to undergo burdensome and extremely costly treat- ments. However, in the field of dentistry it is not nearly as evident that most people subscribe to optimal oral health and are willing to submit to burden- some and costly treatments. If they choose to spend their money on alternative objectives, such as a family vacation or a new car, or if they lack dental insurance and simply cannot afford treat- ment, they will perhaps lose their teeth, but they will not die, and they can have a fairly normal life. Now, if a patient’s overarching goal regarding his dentition is not optimal health, but maybe a much more limited goal of freedom from pain, it does not make sense to force this patient and his den- tist to abide by protocols and guidelines that as- sume optimal dental health is the goal. 19 guideline prescribes, he advises the patient to consult a periodontologist. The patient refuses and asks the dentist to remove the calculus. of 10 years What should the dentist do? Would it make any difference if the dentist found a carcinoma and advised the patient to visit an oro- maxillary facial surgeon? this con- This chapter was written by Wolter Brands Further reading The pa- ADA (2013). Clinical Practice Guidelines Handbook: Evidence-Based Dentistry. Available at: http:// ebd.ada.org/~/media/EBD/Files/ADA_Clinical_ Practice_Guidelines_Handbook-2013.ashx Brands WG, van der Ven J (2015). Evidence-based clinical guidelines in dental practice. Guidelines: professional autonomy and right of self-de- termination. Ned Tijdschr Tandheelkd, 122: 331–336. Broers DLM, Brands WG, Jongh A de, Welie JVM (2010). Deciding about patients’ requests for extraction: ethical and legal guidelines. J Am Dent Assoc, 141:195–203. Gitterman A, Knight C (2013). Evidence-guided practice: integrating the science and art of so- cial work. Families in Society: The Journal of Contemporary Social Services, 94(2):70–78. Niederman R, Richards D, Brands W (2012). The changing standard of care. JADA, 143(5):434–437. Osborne JW, Summitt JB (1998). Extension for prevention: is it relevant today? Am J Dent, 11(4):189–196. Sonneveld R, Brands WG, Bronckhorst E, Welie J, Truin GJ (2013). Patients’ priorities in assessing organizational aspects of a general dental prac- tice. Int Dent J, 63(1):30–38. 21 Chapter 4: duty to treat tions? In this chapter we will use the term patient of record for patients who have indicated that they wish to have a long-term professional relationship

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