Conflicting ethical issues in dentistry

INTRODUCTION

Code of ethics is the foundation of clinical conduct in healthcare. Failure to sustain ethical behavior leads to a lack of trust between health professionals and patients, which can jeopardize treatment performance and effectiveness.^1,2 The ethical principles in healthcare derived long ago when Hippocrates developed the fundamental principles of ethics. The famous Hippocratic Oath, a solemn duty to abstain from wrongdoing and to treat patients with confidentiality and to the best of one's ability, remains the foundation of the medical and dentistry professions' code of ethics.³ Ethics are imposed by moral obligation rather than by profession or law. It governs with the character and conduct to discipline, educate, and motivate people. Ethics is an unwritten code of conduct that includes both professional behavior and judgment between what is right and wrong.⁴

The ethical challenges confronting dentists are expanding and becoming more complex in recent years than in the past. The dental practice is changing dramatically because of liability problems, socioeconomic status, and changes in the ecosystem. As a result, dentists must be familiar with the code of ethics. Decisions might be simple at times, but they can also be challenging. The American Dental Association (ADA) established five fundamental principles of ethics i.e., Patient autonomy, nonmaleficence (to do no harm), beneficence, justice, and veracity (truthfulness).⁵ Before diagnosing and implementing oral healthcare services, ethical values must be assessed and integrated into decision-making. Bioethics aims to ensure patient safety, higher quality healthcare services, and sound judgment in tackling ethical issues.^6,7

PRINCIPLES OF ETHICS

Autonomy

This principle postulates that dentists must respect their patients' self-determination and confidentiality. “He must explain to the patient the treatment planned, the risks associated, and the alternative therapies, and ensure that adequate consent is acquired.’’ According to the General Dental Councils.⁸

When delivering information to a patient about a treatment process, the risk and benefits associated with it should be communicated to the patient's level of knowledge and understanding so that they have a fair and balanced assessment of the situation.⁶ There are three fundamental elements of treatment consent: competence, voluntariness, and knowledge: (i) competence' refers to the patient's ability to comprehend the nature of the treatment as well as the repercussions of undergoing or refusing the treatment, (ii) voluntariness" refers to the patient's free decision to agree to the therapy and (iii) knowledge" refers to providing the patient with sufficient, understandable knowledge of the suggested and alternative treatments.⁹

There are two types of consent: (i) expressed consent-when the patient explicitly agrees to the treatment. This can be done either orally or in writing. In ethical guidelines for dentists, the General Dental Council requires that written consent be acquired before administering general anesthesia and sedation, (ii) implied consent- when it is understandable to draw the conclusion based on the patient's behavior. The mere fact that a patient enters the clinic and sits in the dental chair constitutes implied consent to the examination, but nothing more.

According to the law, there are two forms of legal consent based on the quality of information disclosed to the patient: (i) threshold consent requires only a basic understanding of the treatment plan and serves as a defense to a battery claim and (ii) informed consent is a defense to a negligence claim since it provides awareness of the benefits and risks of the procedure.⁸

The following scenario depicts a case where the patient is expecting a treatment opposite to that of a dentist’s: the patient’s upper jaw has six remaining teeth; he wants tooth extractions and a total denture replacement. However, the dentist recommends periodontal therapy for the remaining teeth, followed by crowns and a partial denture. The patient refuses to accept the advice and insists on tooth extractions and a whole denture. In this scenario the dentist must inform the patient about the importance of retaining natural teeth, as well as the differences between partial and total dentures, then this must be accepted as a fully informed autonomous decision. The dentist is aware that the chosen treatment is not the best one, yet he respects the idea of patient autonomy by honoring his decision.¹⁰

Paternalism is defined as disregarding the desires of fully autonomous patients in the name of doing good. It seems to be the behavior of parents toward their immature, minor-aged children. The dentist is most likely operating in this manner for good motives and a desire to do good. It is possible that the dentist is unaware of the ethical dilemma and is still urging his or her patient to accept the recommended procedure. Of course, even with the best of intentions, this is not an ethically acceptable behavior.^11,12

However, there are occasions when a patient is incapable of making the correct decision. In situations like these where estimating the danger associated with a complicated dental procedure, an incompetent individual, such as a mentally challenged person or a minor patient, will be unable to make a correct, autonomous judgment.¹⁰ Consent is requested from a parent or legal guardian for patients under the age of minority or adults with mental disorders. Any adult accompanying the young patient who is not a legal guardian is not permitted by law to consent for dental treatment.^13,14

Confidentiality is the foundation of any professional relationship. In terms of the law, consent and legal rights to confidentiality are based not just on age but also on the capacity to understand. It is important to note that the personal data belongs to the patient, not the dentist. As a result, the patient may authorize the release of any information to a third party.

Consider a patient who had an epileptic fit during surgery and then requests that the dentist keep this information private. He informs you that because he is a self-employed lorry driver, he may lose his job if he loses his driving license. Despite your efforts to persuade the patient to seek additional assistance from his physician, he refuses and leaves the practice. The conclusion will be drawn based on a balance between nonmaleficence and beneficence whether the patient might not have another seizure or if he does have another seizure while driving, he might end up risking his life as well as others.⁸ However, according to the principle of patient confidentiality established by the General Dental Council of the United Kingdom states that in rare circumstances, it may be appropriate to make patient confidentiality known without the patient's consent if it is in the public or the patient's interest.¹⁵

Certain illnesses, such as HIV, tuberculosis, and viral hepatitis, must be reported to public health authorities because failure to do so poses a high risk of harm to the patient or others. Similarly, if a patient threatened to commit a felony that would probably lead to serious injury to another person, the health care practitioner would be required to break patient confidentiality and report to the concerned authority.¹⁶

Consider another case scenario where a 25-year-old lady has been your patient for 5 years. She has an inherited disorder, amelogenesis imperfecta with an autosomal recessive pattern that causes her teeth to be deformed, severely discolored, and characterized by peculiar pits and grooves. Her dentition has now been entirely restored, and she sought an appointment for her fiancé since she was so pleased with the results. She expressly requests that you not inform him about her situation. The dentist's first instinct is that the patient's amelogenesis imperfecta history should not be divulged to the patient's fiancé. Given that amelogenesis imperfecta is an inherited trait that may impact the couple's children, the dentist may be afraid that the patient's disorder would go unnoticed by the fiancé, despite posing potential genetic hazards to their progeny. While the dentist understands the need to protect the patient's confidentiality, he or she may be concerned about the ramifications of the fiancé discovering that information concerning the patient's condition was suppressed. Such a reaction could be the precursor of a regulatory complaint or a lawsuit claim. In this kind of conflicting situation where the dentist wants to honor the ethical principles of autonomy and beneficence and respect confidentiality but at the same time, he wants to respect the principle of nonmaleficence by preventing potential harm to future children. Amelogenesis imperfecta is not a fatal hereditary condition, and the degree of disease manifestation might vary based on other factors such as gene location and new mutations. Although the emergence of this disease cannot be avoided, the damaged dentition can be efficiently treated. As a result, this illness does not fit the criteria for disclosing personal health information, and patient confidentiality must be preserved.^17,18 In complex situations like these, the guidance from the British Dental Association as well as the GDC ethical code of conduct is very helpful.¹⁹

Patient autonomy is a cornerstone in dental ethics, and it is reflected in the provision to get the patient's voluntary and informed consent well before clinical intervention.⁸

Nonmaleficence

It is originated from the Latin phrase ‘maxim primum nonnocere,' which means 'first, do no harm.' It states that the dentist is responsible for protecting the patient from any injury. Dentists should maintain their knowledge and skills up to date, be aware of their limitations, and understand when and under what circumstances it may be permissible to perform a procedure that may inflict risks to the patient. Dental therapies have a ‘double effect’, which implies that while one problem is being treated, another problem is being created. Dentists should be aware of when to refer a patient to a specialist and when and under what circumstances it is appropriate to assign patient care to auxiliaries. It is the responsibility of dental professionals to notify the patient instantly if he or she has been contracted to blood or any other contagious material at the operatory and make referrals to a qualified medical practitioner for post-exposure care and follow-up. Once a dentist begins a dental procedure for patients, he or she must see the procedure till completion. If the dentist is unable to complete the treatment process for any reason, it is his or her job to recommend the patient to a specialist or colleague.^5,15 Failing to refer the patient to a specialist in this case can lead to negligence.

Furthermore, if a dentist is invited in for a consultation, he or she must not have a vested financial interest in the planned therapy. It is the dentist's obligation to preserve the patient's health and protect them from further possible risks. For example, in a situation like this where an inexperienced dentist is deliberating whether to extract an impacted lower third tooth or refer the patient to an oral surgeon. If the approach is taken, consequences such as fracture and soft tissue damage, prolonged hemorrhage, or other postoperative complications may occur. If a fully ethically conscious dentist can identify these repercussions, the patient will be directed to an oral surgery specialist, who will conduct the surgery in the best possible manner.¹⁰ Lastly, non - maleficence encompasses the dentist's ethical responsibility to avoid interpersonal relationships with patients. Such interactions can impede a dentist's competence to use sound judgment regarding treatment and may undermine the patient's trust in the dentist.²⁰

Beneficence

It is derived from the Latin term benefactum, meaning "good deed." According to this philosophy, dentists must practice benefiting their patients. It is critical that dentists give efficient and appropriate care based on the patient's needs. The primary goal of dental treatment should be to provide the patient with improved oral function and/or the aesthetics of their dental set. The success of this goal will be determined by a variety of factors, including the patient's age, general health, underlying anatomy, and patient compliance and application of oral hygiene guidelines. Community services like providing free or discounted dental services to the needy, documenting investigative findings that protect the general public's health, and reporting signs and symptoms associated with domestic violence and child abuse to the appropriate authorities. Each of these areas contributes to the profession's reputation and fulfills the dentist's responsibility to prioritize the patient's well-being.²¹

In some circumstances, the principles of non-maleficence and beneficence contradict one another. If the rule of non-maleficence is given complete priority, an absurd situation may arise: a dentist would not be permitted to intervene invasively even for the purpose of providing relief, which reflects beneficence. Discomforts associated with needle penetration and the following anesthetic effect must be tolerated to prevent more intense pain associated with tooth preparation for a crown/bridge in prosthetic reconstruction. Removing alveolar bone is not recommended unless the technique requires to treat an impacted third molar with a periapical cyst. When a dentist follows the principles listed above, he or she will act in the following manner: he or she will intend not to cause damage or discomfort and will use an anesthetic. A dentist implements a preventative program by adhering to the rule of disease prevention. By eliminating cavities and implementing appropriate repairs, the dentist adheres to the guideline of limiting harm. Finally, if the patient's wants and dental indications align, the dentist is performing well by completing an aesthetic endeavor. According to the priorities, prevention takes precedence over damage removal, which is sensible and logical.¹⁰

Justice

The principles of justice mandate that all patients be treated without prejudice irrespective of their race, gender, nationality, religion, political affiliation, or social standing. Appearance, education level, and even sexual orientation should not have any influence on the dentist's stance toward the patient.¹⁰ They should not face discrimination based on their HIV status. An individual who is elderly, unwell, or differently abled has the same right to dental treatment as someone who is young and healthy. Undoubtedly, the care provided to society's most vulnerable and needy members is an indicator of that community's well-being.⁸ When referring patients to other dental experts, there should be no discrimination. When providing referrals, the main attention should be given to the doctor's technical and interpersonal skills, attitude, and ideology of dental practice. Prior dentist therapy must not interfere with the dental care to be provided by the consulting dentist. However, if he or she observes any grossly negligent therapy by other dentists, it is his or her responsibility to submit a truthful public declaration free of malice.⁵ If a dentist is summoned to deliver professional and expert testimony, the dentist must provide professional testimony free of personal bias.²⁰

The right to be treated is expressed as the principle of justice according to modern ethics. There are three components of this right: (i) being truthful with the patients, (ii) to provide patients with what they are entitled to and (iii) to provide patients with what they need.

It is also evident that these issues are distinct and contradictory to one another.^22,23

To determine what is just and what is unjust dentists must rely on feedback from society to maintain ethical conformity.²⁰

Veracity

Veracity is a fundamental principle that revolves around being truthful and upholding the trust that is required in the dentist-patient relationship. It emphasizes communicating truthfully without dishonesty and keeping intellectual integrity. This notion illustrates the importance of honesty in billing and advertising. It is unethical for a dental professional to advocate unneeded treatment, such as referring a patient to a specialist or recommending a product for personal gain. Advertising that is based on half-truths is equally unacceptable. Dental professionals should also be honest about their degrees and specialties.⁵ When a health care provider considers 'informed consent as a procedure to guard against potential claims, veracity is essential. For example, if the apices of the tooth are 8 mm from the ID canal, warning of a possibility of inferior dental nerve dysesthesia following removal of lower third molar teeth to adhere to the standard procedure is not being truthful, such knowledge is useless to the patient when determining whether to persist with periodic pericoronitis or have the third molar teeth extracted. Indeed, if a patient decides not to have the tooth extracted on the account of this knowledge, he or she cannot be regarded to have made an informed refusal and the dentist may be held responsible for the patient's persistent pain and discomfort for having failed to provide adequate advice.

'Therapeutic privilege' is used when it is believed that revealing information might be harmful to the patient's well-being. There has been a great deal of confusion about therapeutic privilege which is believed to be confined to the most exceptional cases and is highly unlikely to apply to the provision of dental care.⁸ However, according to modern ethics, the principle of truth should be honored in all circumstances, regardless of whether it benefits or does not benefit the patient. This stance is also endorsed by lawyers, who argue that a patient has the moral right to all truth about his or her sickness and that no one has the authority to limit this right.¹⁰

Other principles of ethics

Negligence: Negligence has been defined as an act of omission (i.e., not doing something that should have been done) or an act of commission (i.e., doing something that should not have been done). For example: not exposing a radiograph when needed or failing to diagnose a periodontal disease would be an act of omission. Extracting a wrong tooth or causing a nerve injury while surgical extraction would be an act of commission.³ Types of dental negligence include: (i) abandonment, (ii) failing to get informed consent, (iii) failing to refer the patient, (iv) failing to warn the patient regarding the side-effects and (v) failing to follow a manufacturer’s instructions

Abandonment: Failure to properly discontinue the professional interaction may result in lawsuits for abandonment. For example, if the dentist terminates the treatment after Direct Pulp Restoration when continuous care is required, abandonment may be charged.

Once the professional relationship has been established a dentist must make sure that a patient is not under the process of treatment before terminating care. Whatever treatment has begun must be completed, and urgent care must be provided for a reasonable period.²⁴

Good Samaritan Law: In legal terminology, a Good Samaritan is somebody who offers help in an emergency to an ill or injured person voluntarily with good faith. According to Good Samaritan law, if the victim is unconscious or unresponsive responder can assist them based on implied consent but if he/she is conscious and can respond properly one must seek permission first. Liability protection is provided by Good Samaritan law against "ordinary negligence." Ordinary negligence is defined as a failure to act professionally. These statutes do not cover "gross negligence" or willful behavior of doctors on duty. Gross negligence is defined as a deliberate and voluntary disregard for the duty to exercise proper care, which is likely to result in serious injury or harm to individuals, property, or both.²⁵

Fidelity: Fidelity is a principle of loyalty. It refers to the relationship that has been established between patients and their healthcare providers, where everything is done for the sake of the patient by improving their oral health, respecting them as a person, and protecting their confidentiality. Each owes the other loyalty; however, the pressure is more on the provider to be worthy of the patient's trust and confidence. Fidelity often creates conflict, for instance, if a dentist promises a patient that he will always be there to serve them and then leaves the facility, the patient may feel deceived. In another case where a manager assures the client and family that they would be here to assist them but then leaves the job, leaving makes the patient feel abandoned.²⁶

CONCLUSION

The code of ethics educates all dentists to prioritise their patients. Dentists have the responsibility to always act in the patient’s best interest and to provide the highest standards of clinical care. Dentists must obtain the patient’s consent before treatment, involve them in decision-making, consider their expectations throughout treatment planning, and maintain their confidentiality. Failure to follow the profession's ethical and moral guidelines can result in charges of gross negligence and, ultimately, the loss of a license to practice. Dental education should incorporate an integrated and humanistic ethics education and proper training methods into the undergraduate dental curriculum. This would lead to greater postgraduate professionalism, increased patient trust, and help in providing a better quality of oral healthcare to patients and society at large.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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