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© 2007 by FDI World Dental Federation

All rights reserved. Up to 10 copies of this document may bemade for your non-commercial personal use, provided that creditis given to the original source. You must have prior writtenpermission for any other reproduction, storage in a retrieval systemor transmission, in any form or by any means. Requests forpermission should be directed to FDI World Dental Federation,13 Chemin du Levant, 01210 Ferney-Voltaire, France; email: [email protected] fax +33 (0) 4 50 40 55 55.

This Manual is a publication of FDI World Dental Federation. It waswritten by John R. Williams, Ph.D. Its contents do not necessarilyreflect the policies of the FDI, except where this is clearly and explicitly indicated.

Cataloguing-in-Publication Data

Williams, John R. (John Reynold), 1942-.

Dental Ethics Manual.

1. Bioethics 2. Dentist-Patient Relations - ethics. 3. Dentist’sRole 4. Dental Research - ethics 5. InterprofessionalRelations 6. Education, Dental - ethics 7. Case reports8. Manuals I.Title

ISBN

0-9539261-5-X

www.fd iwor ldenta l .org

3TABLE OF CONTENTS

Acknowledgments ................................................6

Foreword................................................................7

Preface..................................................................10

Summary ..............................................................12

Introduction ........................................................14- What is dental ethics? ........................................ 14- Why study dental ethics? .................................... 17- Dental ethics, professionalism,

human rights and law ........................................ 19- Conclusion ..........................................................21

Chapter One - Principal Featuresof Dental Ethics ..................................................22- Objectives .......................................................... 22- What’s special about dentistry? .......................... 22- What’s special about dental ethics? .................... 24- Who decides what is ethical?.............................. 28- Does dental ethics change? ................................ 30- Does dental ethics differ from one

country to another? ............................................ 32- The role of the FDI .............................................. 33- How does the FDI decide what is ethical? .......... 33- How do individuals decide what is ethical? ........ 34- Conclusion ..........................................................41

Chapter Two - Dentists and Patients ..................42- Objectives .......................................................... 42- Case study .......................................................... 42 - What’s special about the dentist-patient

relationship? ...................................................... 43- Respect and equal treatment ............................ 44- Communication and consent .............................. 49

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4- Decision making for incompetent patients .......... 53- Confidentiality .................................................... 55- Dealing with uncooperative patients .................. 60- Financial restraints on treatment ........................ 61- Back to the case study ........................................ 63

Chapter Three - Dentists and Society ................65- Objectives .......................................................... 65- Case study ........................................................ 65- What’s special about the

dentist-society relationship? .............................. 66- Dual loyalty........................................................ 68- Resource allocation ............................................ 70- Public health ...................................................... 75- Global health .................................................... 76- Back to the case study ...................................... 80

Chapter Four - Dentists and Colleagues ............81- Objectives .......................................................... 81- Case study .......................................................... 81- Relationships with dentist colleagues,

teachers and students ........................................ 83- Reporting unsafe or unethical practices .............. 86- Relationships with other health professionals ...... 88- Cooperation ...................................................... 89- Conflict resolution .............................................. 91- Back to the case study ........................................ 93

Chapter Five – Ethics and Research ....................94- Objectives .......................................................... 94- Case study .......................................................... 94- Importance of research ...................................... 94- Research in dental practice.................................. 95- Ethical requirements............................................ 98

- Ethics review committee approval .................. 100- Scientific merit ................................................ 101


5- Social value .................................................... 102- Risks and benefits .......................................... 103- Informed consent .......................................... 104- Confidentiality ................................................ 105- Conflict of roles .............................................. 105- Honest reporting of results ............................ 106- Whistle blowing.............................................. 106- Unresolved issues............................................ 107

- Back to the case study ...................................... 108

Chapter Six - Conclusion ..................................109- Rights and privileges of dentists ........................ 109- Responsibilities to oneself ................................ 110- The future of dental ethics................................ 111

Appendix A - Glossary ........................................113(includes words in italic print in the text)

Appendix B - Dental EthicsResources on the Internet ....................................116

Appendix C – Association for Dental Educationin Europe: Profile and Competences for theEuropean Dentist; General Dental Council (U.K.):The First Five Years: A Framework for UndergraduateDental Education; Association of Canadian Facultiesof Dentistry: Competencies for a Beginning DentalPractitioner in Canada; The (USA) Commission onDental Accreditation: Standards for DentalEducation Programs ............................................120

Appendix D - Strengthening Ethics Teachingin Dental Schools..................................................130

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6ACKNOWLEDGMENTS

The author is profoundly grateful to the followingindividuals for providing extensive and thoughtfulcomments on earlier drafts of this Manual:

• Dr. Shashidhar Acharya, Indian Dental Association

• Dr. Ziad Al-Dwairi, Jordan Dental Association

• Dr. Robert Anderton, American Dental Association

• Dr. Habib Benzian, FDI World Dental Federation

• Dr. Igor Kirovski, Macedonian Stomatological Society

• Dr. Bill O’Reilly, Australian Dental Association

• Dr. Peter Swiss, Chairman, FDI Ethics & DentalLegislation Working Group

• Prof. Jos V.M. Welie, Center for Health Policyand Ethics, Creighton University Medical Center,Omaha, USA

• Prof. Nermin Yamalik, Turkish Dental Association

The FDI acknowledges with gratitude the generosityof the World Medical Association in grantingpermission for the adaptation of its Medical EthicsManual for dentists.

The publication of this Manual was made possible byan educational grant from Johnson & Johnson OralHealth Products.


7FOREWORD

It is a privilege and a pleasure to introduce the FDIDental Ethics Manual.

I want to congratulate and thank each and every onewho collaborated in this Dental Ethics Manual. This publication is the result of the FDI’s involvementand active promotion of dental ethics over manyyears.

The FDI World Dental Federation is the global dentalassociation representing more than 135 membercountries. One of the FDI’s roles is to assist themember associations and each dentist in their dailychallenges.

The FDI International Principles of Ethics for theDental Profession states that:

The professional dentist:• will practice according to the art and science of

dentistry and to the principles of humanity• will safeguard the oral health of patients

irrespective of their individual status

The importance of ethics as an integral part of themedical profession – and thus by implication also thedental profession, as dentistry is part and parcel ofgeneral health – has been highlighted already byHippocrates more than 2,000 years ago. The corevalues of “first, do no harm” and “put the patientfirst” apply to this very day.

Practicing dentistry gives rise to a wide spectrum ofpotential ethical dilemmas. Modern technology, age-

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8old cultural beliefs and diverse lifestyles could easilygive rise to misunderstanding and conflict. Thismanual does not list what is right and what is wrong,but provides values and practical examples that willgive food for thought and will guide practitioners inmaking sound ethical decisions in the best interests oftheir patients.

Dental education and training will never be completeunless the curricula of dental schools incorporate acourse on dental and medical ethics. The FDI truststhat this Manual will become a source of referencefor dental students and practitioners alike.

During my Presidency I decided to focus onExcellence, Medical positioning of our professionand Ethics.

• Excellence in our daily practice is an ethicalbehaviour

• Oral health is an intrinsic part of general health;the same fundamental ethos, values and normsguide its practice. Oral healthcare shouldtherefore be approached with the same diligenceas medical care.

• Ethical behaviour gives credibility and trust -indispensable for the good outcome of ourtreatments

As dentists we experience daily the privileged patient– practitioner relationship and we have to nurture it.


9In order to live up to the age-old adage of puttingthe patient first, a few practical aspects should alwaysbe upfront in our minds: respect all patients andempower them by providing them with adequateinformation and by involving them in determiningtreatment plans and decisions about their health. Theprimary consideration must always be the patient’shealth and well-being.

The FDI hopes this Manual will be an inspiration foreveryone in the oral health professions and in thebest interests of their patients.

Dr. Michèle Aerden

PresidentFDI World Dental Federation

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10PREFACE

Every day oral health professionals are subject to strictroutines and stressful situations which can easilyresult in decisions or actions that could on reflectionseem to be doubtful and maybe even unethical. ThisManual provides the opportunity for dentalpractitioners, educators, students and all involved inpatient care to reflect on the role that we asprofessionals have to play and how we should act toensure that in all circumstances we maintain the trustand confidence placed in us by our patients.

The Dental Ethics Manual provides easy andenjoyable, yet educational, reading. The old adage of“when in doubt, it is probably not ethical” is a goodpersonal guideline. The many practical examples inthe Manual cover the wide scope of issues applicableto daily practice and will ensure that readers canrelate to the situation and contemplate how theywould and should handle similar situations in theirwork environment.

The Manual is published in a practical pocket sizeformat and we hope that it will become an invaluableaid to the work routine of dental practices and dentalschools around the globe. We also hope that thisManual will eventually be translated into manylanguages in order to give all involved in dentaleducation and care around the world the opportunityto benefit from the principles conveyed in this book.


11We wish to express our appreciation to the WorldMedical Association for providing the stimulus for thispublication through their Medical Ethics Manual andespecially to our author, Dr John Williams. We alsowish to acknowledge with gratitude the unrestrictedgrant from Johnson & Johnson which made theproduction of this publication possible.

This publication of this Manual fulfils in part the FDImission “to advance and promote the ethics, art,science and practice of dentistry”. Ethical issues arepart of our daily lives. Let us all strive to live up tothe high ideals of our profession by actingprofessionally and ethically in all circumstances in ourprofessional and private lives.

Dr. JT BarnardExecutive DirectorFDI World Dental Federation

Dr. Peter SwissChairmanFDI Ethics & Dental Legislation Working Group

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12SUMMARY

Dentists everywhere are members of a professionwith very high ethical standards. For many years theFDI World Dental Federation has been activelyengaged in developing ethics policies for dentistry,most notably the International Principles of Ethicsfor the Dental Profession. In order to assist dentistsin understanding and implementing these principles,the FDI has commissioned this Dental Ethics Manual.The Manual is offered as an educational resource todental students and practising dentists throughoutthe world.

There already exists an excellent and rapidlyexpanding literature on dental ethics, and this Manualis intended to complement rather than compete withthese books and articles. The Manual provides aconcise introduction to the basic concepts of ethicsand their application to the most common issuesencountered by dentists in their daily practice.Learning objectives are provided for the Manual as awhole and for each chapter. Most chapters beginwith a typical case that is revisited at the end of thechapter in the light of what was presented there.Resources for further study and reflection are given inthe Manual’s appendices.


13In addition to its emphasis on the practical applicationof ethical principles, the Manual focuses on therelationship among ethics, professionalism andhuman rights. Human rights are the basis of theethical duties and responsibilities that dentists sharewith all other persons. However, as members of aprofession, dentists have duties and responsibilitiesover and above those of other citizens. The Manualidentifies and discusses these requirements as theyarise in dentists’ relationships with their patients,society and colleagues and in the context of dentalresearch.

The Manual concludes with a consideration of therights and privileges of dentists, their responsibilitiesto themselves, and the future of dental ethics.

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14INTRODUCTION

What is dental ethics?Ethics is an intrinsic component of dental practice.Every day dentists are faced with situations that callfor ethical judgment and behaviour. Here are fourtypical cases:

1. Dr. P has been in practice for 32 years. His olderpatients appreciate his devoted service and aregenerally quite happy to let him decide whattreatment they will have. Some of his youngerpatients, on the other hand, resent what theyconsider to be his paternalistic approach and thelack of information about treatment options. WhenCarole J, a 28-year-old accountant, asks Dr. P for areferral to an orthodontist to correct a mildoverbite, Dr. P refuses because it is his professionalopinion that the treatment is unnecessary. He iswilling to lose a patient rather than compromisehis principle that he should only provide beneficialtreatments to patients and will neither mention norrefer patients for treatments that he considersunnecessary or harmful.

2. Dr. S is one of only two dentists in her community.Between them they have just managed to providebasic oral care to the population. Recently hercolleague has changed his practice to focus ontechnically and aesthetically advanced services thatonly adequately insured or middle and upper classpatients can afford. As a result, Dr. S isoverwhelmed by patients requiring basic care. Sheis reluctant to ration her services but feels that shehas no choice. She wonders what is the fairest wayto do so: by favouring her previous patients over


15those of her colleague; by giving priority toemergency cases; by establishing a waiting list sothat all will get treated eventually; or by someother way.

3. Dr. C, a newly qualified endodontist, has just takenover the practice of the only endodontist in amedium-sized community. The four generalpractice dentists in the community are relieved thatthey can continue their referrals withoutinterruption. During his first three months in thecommunity, Dr. C is concerned that a significantnumber of the patients referred by one of thegeneral practice dentists show evidence ofsubstandard treatment. As a newcomer, Dr. C isreluctant to criticise the referring dentist personallyor to report him to higher authorities. However,she feels that she must do something to improvethe situation.

4. Dr. R, a general practice dentist in a small ruraltown, is approached by a contract researchorganisation (C.R.O.) to participate in a clinical trialof a new sealant. He is offered a sum of money foreach patient that he enrols in the trial. The C.R.O.representative assures him that the trial hasreceived all the necessary approvals, including onefrom an ethics review committee. Dr. R has neverparticipated in a trial before and is pleased to havethis opportunity, especially with the extra money.He accepts without inquiring further about thescientific or ethical aspects of the trial.

These case studies will be discussed further in thefollowing chapters. Each of them invites ethicalreflection. They raise questions about the behaviour

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1. Words in Italics are defined in the glossary at the end of the manual(Appendix A).

and decision-making of dentists – not scientific ortechnical questions such as how to apply a localanaesthetic or extract an impacted wisdom tooth, butquestions about values,1 rights and responsibilities.Dentists face these kinds of questions just as often asscientific and technical ones.

In dental practice, no matter what the specialty or thesetting, some questions are much easier to answerthan others. For example, repairing a caries lesion isgenerally unproblematic for dentists who areaccustomed to performing this procedure. At theother end of the spectrum, there can be greatuncertainty or disagreement about how to treat someconditions, even common ones such as periodontaldisease. Likewise, ethical questions in dentistry arenot all equally challenging. Some are relatively easy toanswer, mainly because there is a well-developedconsensus on the right way to act in the situation (forexample, the dentist should always obtain validconsent to treatment). Others are much moredifficult, especially those for which no consensus hasdeveloped or where all the options have drawbacks(for example, rationing of scarce resources).

So, what exactly is ethics and how does it helpdentists deal with such questions? Put simply, ethics isthe study of morality — careful and systematicreflection on and analysis of moral decisions andbehaviour, whether past, present or future. Morality isthe value dimension of human decision-making andbehaviour. The language of morality includes nounssuch as ‘rights’, ‘responsibilities’ and ‘virtues’ andadjectives such as ‘good’ and ‘bad’ (or ‘evil’), ‘right’and ‘wrong’, ‘just’ and ‘unjust’. According to thesedefinitions, ethics is primarily a matter of knowing


17whereas morality is a matter of doing. Their closerelationship consists in the concern of ethics toprovide rational criteria for people to decide orbehave in some ways rather than others.

Since ethics deals with all aspects of humanbehaviour and decision making, it is a very large andcomplex field of study with many branches orsubdivisions. The focus of this Manual is dentalethics, the branch of ethics that deals with moralissues in dental practice. Dental ethics is closelyrelated, but not identical, to bioethics. Whereasdental ethics focuses primarily on issues arising in thepractice of dentistry, bioethics is a very broad subjectthat is concerned with the moral issues raised bydevelopments in the biological sciences moregenerally. Bioethics also differs from dental ethicsinsofar as it does not require the acceptance ofcertain values that are specific to a particular healthcare practice, in our case to oral health care. InChapter One we will discuss which values arefundamental to the practice of dentistry.

As an academic discipline, dental ethics hasdeveloped its own specialised vocabulary, includingmany terms that have been borrowed fromphilosophy. However, dental ethics is not philosophyapplied to the practice of dentistry, and this Manualdoes not presuppose any familiarity with philosophyin its readers. Therefore definitions of key terms areprovided either where they occur in the text or in theglossary at the end of the Manual.

Why study dental ethics?“As long as the dentist is a knowledgeable and skilfulclinician, ethics doesn’t matter.”

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18“Ethics is learned in the family, not in dental school.”

“Dental ethics is learned by observing how seniordentists act, not from books or lectures.”

“Ethics is important, but our curriculum is already toocrowded and there is no room for ethics teaching.”

These are some of the common reasons given for notassigning ethics a major role in the dental schoolcurriculum. Each of them is partially, but only partially,valid. Increasingly throughout the world, dentalschools are realising that they need to provide theirstudents with adequate time and resources forlearning ethics. They have received strongencouragement to move in this direction fromorganisations such as the FDI World Dental Federationas well as many other international and nationalorganisations concerned with dental health. By wayof example Appendix C contains a digest ofstatements on the ethical competencies of dentists asdeveloped by the Association for Dental Education inEurope, the General Dental Council (U.K.), theAssociation of Canadian Faculties of Dentistry and the(USA) Commission on Dental Accreditation.

The importance of ethics in dental education willbecome apparent throughout this Manual. Tosummarise, ethics is and always has been an essentialcomponent of dental practice. Ethical principles suchas respect for persons, informed consent andconfidentiality are basic to the dentist-patientrelationship. However, the application of theseprinciples in specific situations is often problematic,since dentists, patients, their family members andother oral health personnel may disagree about what


19is the right way to act in a situation. Moreover,developments in dental science and technology andchanges in societal values and structures areconstantly posing new ethical challenges. The studyof ethics prepares dental students and practisingdentists to recognise and deal with such issues in arational and principled manner, whether in theirinteractions with patients, society or their colleaguesand in the conduct of dental research.

Dental Ethics, Professionalism, Human Rights and LawDentistry has been a recognised profession for lessthan two centuries. Previously it overlapped withmedicine and so the origins of dental ethics can befound in traditional medical ethics. As will be seen inChapter One, ethics has been an integral part ofmedicine at least since the time of Hippocrates, thefifth century B.C.E. (before the Christian era) Greekphysician who is regarded as a founder of medicalethics. The concept of medicine as a profession isoften attributed to Hippocrates, whereby physiciansmake a public promise that they will place theinterests of their patients above their own interests(see Chapter Three for further explanation). The closerelationship of ethics and professionalism in dentistrywill be evident throughout this Manual.

In recent times both medical ethics and dental ethicshave been greatly influenced by developments inhuman rights. In a pluralistic and multiculturalworld, with many different moral traditions, themajor international human rights agreements canprovide a foundation for dental ethics that isacceptable across national and cultural boundaries.Moreover, dentists sometimes have to deal with

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20dental problems resulting from violations of humanrights, such as forced migration and torture. They aregreatly affected by the debate over whether healthcare is a human right, since the answer to thisquestion in any particular country determines to alarge extent who has access to dental care. ThisManual will give careful consideration to humanrights issues as they affect dental practice.

Dental ethics is also closely related to law. In mostcountries there are laws that specify how dentists arerequired to deal with ethical issues in patient care andresearch. In addition, the dental licensing andregulatory officials in each country can and do punishdentists for ethical violations. Usually therequirements of dental ethics and law are similar. Butethics should not be confused with law. Onedifference between the two is that laws can differsignificantly from one country to another while ethicsis generally applicable across national boundaries. Inaddition, ethics quite often prescribes higherstandards of behaviour than does the law, andoccasionally situations may arise where the twoconflict. In such circumstances dentists must use theirown best judgement whether to comply with the lawor follow ethical principles. Where unjust laws conflictwith ethical principles, dentists should workindividually and collectively to change the laws.Although dentists should be familiar with the legalaspects of dentistry, the focus of this Manual is onethics, moral values and professional commitmentsrather than law.


21ConclusionDentistry is both a science and an art. Science dealswith what can be observed and measured, and acompetent dentist recognises the signs of oral diseaseand knows how to restore good oral health. Butscientific dentistry has its limits, particularly in regardto human individuality, culture, religion, freedom,rights and responsibilities. The art of dentistry involvesthe application of dental science and technology toindividual patients, families and communities, no twoof which are identical. By far the major part of thedifferences among individuals, families andcommunities is non-physiological, and it is inrecognising and dealing with these differences thatthe arts, humanities and social sciences, along withethics, play a major role. Indeed, ethics itself isenriched by the insights and data of these otherdisciplines; for example, a theatrical presentation of aclinical dilemma can be a more powerful stimulus forethical reflection and analysis than a simple casedescription.

This Manual can provide only a basic introduction todental ethics and some of its central issues. It isintended to give you an appreciation of the need forcontinual reflection on the ethical dimension ofdentistry, and especially on how to deal with theethical issues that you will encounter in your ownpractice. A list of resources is provided in Appendix Bto help you deepen your knowledge of this field.

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22CHAPTER ONE –

PRINCIPAL FEATURES OF DENTAL ETHICS

ObjectivesAfter working through this chapter you should be able to:• explain why ethics is important to dentistry• identify the major sources of dental ethics• recognise different approaches to ethical

decision-making, including your own.

What’s Special about Dentistry?In virtually every part of the world, being a dentisthas meant something special. People come todentists for help with some of their most pressingneeds – relief from pain and suffering and restorationof oral health and well-being. They allow dentists tosee, touch and manipulate their bodies and theydisclose information about themselves that theywould not want others to know. They do thisbecause they trust their dentists to act in their best interests.

As noted above, dentistry is a recognised profession.At the same time, however, it is a commercialenterprise, whereby dentists employ their skills toearn a living. There is a potential tension betweenthese two aspects of dentistry and maintaining anappropriate balance between them is often difficult.Some dentists may be tempted to minimise theircommitment to professionalism in order to increasetheir income, for example by aggressive advertisingand/or specialising in lucrative cosmetic procedures. Iftaken too far, such activities can diminish the public’srespect for and trust in the entire dental profession,


23with the result that dentists will be regarded as justanother set of entrepreneurs who place their owninterests above those of the people they serve. Suchbehaviour is in conflict with the requirement of theFDI International Principles of Ethics for theDental Profession that “the dentist should act in amanner which will enhance the prestige andreputation of the profession.”

Because the commercial aspect of dentistrysometimes seems to prevail over the professionalaspect, the status of dentists is deteriorating in somecountries. Patients who used to accept dentists’advice unquestioningly sometimes ask dentists todefend their recommendations if these are differentfrom information obtained from other oral healthpractitioners or the Internet. If they are dissatisfiedwith the results of dental treatment, no matter whatthe cause, an increasing number of patients areturning to the courts to obtain compensation fromdentists. Moreover, many dentists feel that they areno longer as respected as they once were. In somecountries, control of oral health care has movedsteadily away from dentists to non-dental managersand bureaucrats, some of whom tend to see dentistsas obstacles to rather than partners in the provisionof health care for all in need. Some procedures thatformerly only dentists were capable of performing arenow done by dental hygienists, therapists, assistantsor denturists.

Despite these changes impinging on the status ofdentists, dentistry continues to be a profession that ishighly valued by the people who need its services. Italso continues to attract large numbers of the mostgifted, hard working and dedicated students. In order

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24to meet the expectations of patients, students andthe general public, it is important that dentists knowand exemplify the core values of dentistry, especiallycompassion, competence and autonomy. Thesevalues, along with respect for fundamental humanrights, serve as the foundation of dental ethics.

What’s Special About Dental Ethics?Compassion, competence and autonomy are notexclusive to dentistry. However, the practice ofdentistry requires dentists to exemplify these values toa higher degree than in other occupations, includingsome other professions.

Compassion, defined as understanding and concernfor another person’s distress, is essential for thepractice of dentistry. In order to deal with the patient’sproblems, the dentist must identify the symptoms thatthe patient is experiencing and their underlying causesand must want to help the patient achieve relief.Patients respond better to treatment if they perceivethat the dentist appreciates their concerns and istreating them rather than just their illness.

A very high degree of competence is both expectedand required of dentists. A lack of competence canhave serious consequences for patients. Dentistsundergo a long training period to ensurecompetence, but considering the rapid advance ofdental knowledge, it is a continual challenge for themto maintain their competence. Moreover, it is not justtheir scientific knowledge and technical skills thatthey have to develop and maintain but their ethicalknowledge, skills and attitudes as well, since newethical issues arise with changes in dental practiceand its social and political environment.


25Autonomy, or self-determination, is the core value ofdentistry that has evolved the most over the years.Individual dentists have traditionally enjoyed a highdegree of clinical autonomy in deciding where andhow to practice. Dentists collectively (the dentalprofession) have been free to determine thestandards of dental education and dental practice. Asdo physicians, dentists consider that clinical andprofessional autonomy benefits not just themselvesbut patients as well, since it frees dentists fromgovernment and corporate restraints on providingoptimal treatment for patients. As will be evidentthroughout this Manual, governments and otherauthorities are increasingly restricting the autonomyof dentists. Nevertheless, dentists still value theirautonomy and try to preserve it as much as possible.At the same time, there has been a widespreadacceptance by dentists worldwide of patientautonomy, which means that patients should be theultimate decision makers in matters that affectthemselves. This Manual will deal with examples ofpotential conflicts between the dentist’s autonomyand respect for patient autonomy.

Besides its adherence to these three core values, dentalethics differs from the general ethics applicable toeveryone by being publicly proclaimed in a code ofethics or similar document. Codes vary from onecountry to another and even within countries, but theyhave many common features, including commitmentsthat dentists will consider the interests of their patientsabove their own, will not discriminate against patientson the basis of race, religion or other human rightsgrounds and will protect the confidentiality of patientinformation. In 1997 the FDI adopted theInternational Principles of Ethics for the DentalProfession for dentists everywhere.

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FDI World Dental FederationInternational Principles of Ethics for

the Dental Profession

These International Principles of Ethics for the DentalProfession should be considered as guidelines for everydentist. These guidelines cannot cover all local, national,traditions, legislation or circumstances.

The professional dentist:• will practice according to the art and science of dentistry

and to the principles of humanity• will safeguard the oral health of patients irrespective of

their individual status

The primary duty of the dentist is to safeguard the oralhealth of patients. However, the dentist has the right todecline to treat a patient, except for the provision ofemergency care, for humanitarian reasons, or where thelaws of the country dictate otherwise.

• should refer for advice and/or treatment any patientrequiring a level of competence beyond that held

The needs of the patient are the overriding concern and the dentist should refer for advice or treatment any patient requiring a level of dental competence greater than he/she possesses.

• must ensure professional confidentiality of all informationabout patients and their treatment

The dentist must ensure that all staff respect patientsconfidentiality except where the laws of the country dictate otherwise.

• must accept responsibility for, and utilise dental auxiliariesstrictly according to the law


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The dentist must accept full responsibility for all treatmentundertaken, and no treatment or service should bedelegated to a person who is not qualified or is not legallypermitted to undertake this.

• must deal ethically in all aspects of professional life andadhere to rules of professional law

• should continue to develop professional knowledge and skills

The dentist has a duty to maintain and update professionalcompetence through continuing education through his/heractive professional life.

• should support oral health promotion

The dentist should participate in oral health education andshould support and promote accepted measures to improvethe oral health of the public.

• should be respectful towards professional colleagues and staff

The dentist should behave towards all members of the oralhealth team in a professional manner and should be willingto assist colleagues professionally and maintain respect fordivergence of professional opinion.

• should act in a manner which will enhance the prestigeand reputation of the profession.

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28Who Decides What is Ethical?Ethics is pluralistic. Individuals disagree amongthemselves about what is right and what is wrong,and even when they agree, it is often for differentreasons. In some societies, this disagreement isregarded as normal and there is a great deal offreedom to act however one wants, as long as it doesnot violate the rights of others. This individualfreedom may present a challenge for dentists andtheir patients, whose ethical differences must beovercome in order to reach their common goal. Inmore traditional societies, there is greater agreementon ethics and greater social pressure, sometimesbacked by laws, to act in certain ways rather thanothers. In such societies culture and religion oftenplay a dominant role in determining ethical behaviour.

The answer to the question, “who decides what isethical for people in general?” therefore varies fromone society to another and even within the samesociety. In liberal societies, individuals have a greatdeal of freedom to decide for themselves what isethical, although they will likely be influenced by theirfamilies, friends, religion, the media and otherexternal sources. In more traditional societies, familyand clan elders, religious authorities and politicalleaders usually have a greater role than individuals indetermining what is ethical.

Despite these differences, it seems that human beingseverywhere can agree on some fundamental ethicalprinciples, namely, the basic human rights proclaimedin the United Nations Universal Declaration ofHuman Rights and other widely accepted andofficially endorsed documents. The human rights thatare especially important for dental ethics include the


29rights to freedom from discrimination, to freedom ofopinion and expression, to equal access to publicservices in one’s country, and to health care.

For dentists, the question, “who decides what isethical?” has until recently had a somewhat differentanswer than for people in general. During the pasttwo centuries the dental profession has developed itsown standards of behaviour for its members, whichare expressed in codes of ethics and related policydocuments. At a global level, the FDI has set forth abroad range of ethical statements that specify thebehaviour required of dentists no matter where theylive and practise (see Appendix B). In many, if notmost, countries dental associations have beenresponsible for developing and enforcing theapplicable ethical standards. Depending on thecountry’s approach to health law, these standardsmay have legal status.

The dental profession’s privilege of being able todetermine its own ethical standards has never beenabsolute, however. For example:

• Dentists have always been subject to the generallaws of the land and have sometimes beenpunished for acting contrary to these laws.

• Some dental organisations are strongly influencedby religious teachings, which impose additionalobligations on their members besides thoseapplicable to all dentists.

• In many countries the organisations that set thestandards for dentists’ behaviour and monitor theircompliance now have a significant non-dentistmembership.

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30The ethical directives of dental associations aregeneral in nature; they cannot deal with everysituation that dentists might face in their practice. Inmost situations, dentists have to decide forthemselves what is the right way to act, but inmaking such decisions, it is helpful to know whatother dentists would do in similar situations. Dentalcodes of ethics and policy statements reflect ageneral consensus about the way dentists should actand they should be followed unless there are goodreasons for acting otherwise.

Does Dental Ethics Change?There can be little doubt that some aspects of dentalethics have changed over the years. Until recentlydentists had the right and the duty to decide howpatients should be treated and there was noobligation to obtain the patient’s informed consent.In contrast, the U.K. General Dental Council nowadvises dentists that: “It is a general legal and ethicalprinciple that you must get valid consent beforestarting treatment or physical investigation, orproviding personal care, for a patient. This principlereflects the right of patients to determine whathappens to their own bodies, and is a fundamentalpart of good practice.” Many individuals now consult the Internet and other sources of healthinformation and are not prepared to accept therecommendations of dentists unless these are fullyexplained and justified. Although this insistence oninformed decision making is far from universal, itdoes seem to be spreading and is symptomatic of amore general evolution in the patient-dentistrelationship that gives rise to different ethicalobligations for dentists than previously.


31Until recently, dentists generally consideredthemselves accountable only to themselves, to theircolleagues in the dental profession and, for religiousbelievers, to God. Nowadays, they have additionalaccountabilities – to their patients, to third partiessuch as managed health care organisations, to dentallicensing and regulatory authorities, and often tocourts of law. These different accountabilities canconflict with one another, as will be evident in thediscussion of dual loyalty in Chapter Three.

Dental ethics has changed in other ways. Whereasuntil recently the sole responsibility of dentists was totheir individual patients, nowadays it is generallyagreed that dentists should also consider the needs ofsociety, for example, in allocating scarce health careresources (cf. Chapter Three). Moreover, advances indental science and technology raise new ethical issues that cannot be answered by traditional dentalethics. Health informatics and electronic patientrecords, changing patterns of practice and expensivenew devices have great potential for benefitingpatients but also potential for harm depending onhow they are used. To help dentists decide whetherand under what conditions they should utilise theseresources, dental associations need to use differentanalytic methods than simply relying on existingcodes of ethics.

Despite these obvious changes in dental ethics, thereis widespread agreement among dentists that thefundamental values and ethical principles of dentistrydo not, or at least should not, change. Since it isinevitable that human beings will always be subject tooral disease, they will continue to have need ofcompassionate, competent and autonomous dentiststo care for them.

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32Does Dental Ethics Differ from One Country to Another?Just as dental ethics can and does change over time,in response to developments in dental science andtechnology as well as in societal values, so does itvary from one country to another depending on thesesame factors. On advertising, for example, there is asignificant difference of opinion among nationaldental associations. Some associations forbid it butothers are neutral and still others accept it undercertain conditions. Likewise, regarding access to oralhealth care, some national associations support theequality of all citizens whereas others are willing totolerate great inequalities. In some countries there isconsiderable interest in the ethical issues posed byadvanced dental technology whereas in countries thatdo not have access to such technology, these ethicalissues do not arise. Dentists in some countries areconfident that they will not be forced by theirgovernment to do anything unethical while in othercountries it may be difficult for them to meet theirethical obligations, for example, to maintain theconfidentiality of patients in the face of police orarmy requirements to report ‘suspicious’ injuries; anysuch encouragement of dentists to act unethicallyshould be a matter of great concern.Although these differences may seem significant, thesimilarities are far greater. Dentists throughout theworld have much in common, and when they cometogether in organisations such as the FDI, they usuallyachieve agreement on controversial ethical issues,though this often requires lengthy debate. Thefundamental values of dental ethics, such ascompassion, competence and autonomy, along withdentists’ experience and skills in all aspects ofdentistry, provide a sound basis for analysing ethical


33issues in dentistry and arriving at solutions that are inthe best interests of individual patients and citizensand public health in general.

The Role of the FDIAs the only international organisation that seeks torepresent all dentists, regardless of nationality orspecialty, the FDI has undertaken the role ofestablishing general standards in dental ethics thatare applicable worldwide. In addition to theInternational Principles of Ethics for the DentalProfession, the FDI has adopted policy statements onmany specific ethical issues as well as other issuesrelated to oral health, oral health policies and thedental profession (see Appendix B). The FDI GeneralAssembly frequently revises existing policies andadopts new ones.

How Does the FDI Decide What is Ethical?Achieving international agreement on controversialethical issues is not an easy task, even within arelatively cohesive group such as dentists. The FDIWorking Group on Ethics and Dental Legislation,through the Dental Practice Committee, is responsiblefor preparing statements on ethical issues, andamendments to existing statements, for considerationand approval by the Council and General Assembly. In deciding what is ethical, the FDI draws upon thehistory of dental ethics as reflected in its previousethical statements. It also takes note of otherpositions on the topic under consideration, both ofnational and international organisations and ofindividuals with skill in ethics. On some issues, suchas informed consent, the FDI finds itself in agreementwith the majority view. On others, such as the

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34confidentiality of personal dental information, theposition of dentists may have to be promotedforcefully against those of governments, healthsystem administrators and/or commercial enterprises.A defining feature of the FDI’s approach to ethics isthe priority that it assigns to the individual patient orresearch subject. As the International Principles ofEthics for the Dental Profession state, “The needsof the patient are the overriding concern….”

How Do Individuals Decide What is Ethical?For individual dentists and dental students, dentalethics does not consist simply in following therecommendations of the FDI or other dentalorganisations. These recommendations are usuallygeneral in nature and individuals need to determinewhether or not they apply to the situation at hand.Moreover, many ethical issues arise in dental practicefor which there is no guidance from dentalassociations. Individuals are ultimately responsible formaking their own ethical decisions and forimplementing them.

There are different ways of approaching ethical issuessuch as the ones in the cases at the beginning of thisManual. These can be divided roughly into twocategories: non-rational and rational. It is importantto note that non-rational does not mean irrational(that is, contrary to reason) but simply that it is to bedistinguished from the systematic, reflective use ofreason in decision making.


35Non-rational approaches:

• Obedience is a common way of making ethicaldecisions, especially by children and those whowork within authoritarian structures (for example,the military, police, some religious organisations,many businesses). Morality consists in following therules or instructions of those in authority, whetheror not you agree with them.

• Imitation is similar to obedience in that itsubordinates one’s judgement about right andwrong to that of another person, in this case, a role model. Morality consists in following theexample of the role model. This has been perhaps the most common way of learning dentalethics by aspiring dentists, with the role modelsbeing the senior dentists and the mode of morallearning being observation and assimilation of thevalues portrayed.

• Feeling or desire is a subjective approach to moraldecision-making and behaviour. What is right iswhat feels right or satisfies one’s desire; what iswrong is what feels wrong or frustrates one’s desire.The measure of morality is to be found within eachindividual and, of course, can vary greatly from oneindividual to another, and even within the sameindividual over time.

• Intuition is an immediate perception of the rightway to act in a situation. It is similar to desire inthat it is entirely subjective; however, it differsbecause of its location in the mind rather than thewill. To that extent it comes closer to the rationalforms of ethical decision-making than do

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36obedience, imitation, feeling and desire. However, itis neither systematic nor reflexive but directs moraldecisions through a simple flash of insight. Likefeeling and desire, it can vary greatly from oneindividual to another, and even within the sameindividual over time.

• Habit is a very efficient method of moral decision-making since there is no need to repeat asystematic decision-making process each time amoral issue arises similar to one that has been dealtwith previously. However, there are bad habits (forexample, lying) as well as good ones (for example,truth-telling); moreover, situations that appearsimilar may require significantly different decisions.As useful as habit is, therefore, one cannot place allone’s confidence in it.

Rational approaches:

As the study of morality, ethics recognises theprevalence and usefulness of these non-rationalapproaches to decision-making and behaviour.However, it is primarily concerned with rationalapproaches. Four such approaches are deontology,consequentialism, principlism and virtue ethics:

• Deontology involves a search for well-foundedrules that can serve as the basis for making moraldecisions. An example of such a rule is, “Treat allpeople as equals.” Its foundation may be religious(for example, the belief that all God’s humancreatures are equal) or non-religious (for example,human beings share almost all of the same genes).Once the rules are established, they have to beapplied in specific situations, and there is often


37room for disagreement about what the rules require(for example, whether the equality of all humanbeings entitles them to basic oral health care).

• Consequentialism bases ethical decision-makingon an analysis of the likely consequences oroutcomes of different choices and actions. The rightaction is the one that produces the best outcomes.Of course there can be disagreement about whatcounts as a good outcome. One of the best-knownforms of consequentialism, namely utilitarianism,uses ‘utility’ as its measure and defines this as ‘thegreatest good for the greatest number’. Otheroutcome measures used in healthcare decision-making include cost-effectiveness and quality of lifeas measured in QALYs (quality-adjusted life-years) orDALYs (disability-adjusted life-years). Supporters ofconsequentialism generally do not have much usefor principles; principles are too difficult to identify,prioritise and apply, and in any case they do nottake into account what in their view really matter inmoral decision making — the outcomes. However,this setting aside of principles leavesconsequentialism open to the charge that it acceptsthat ‘the end justifies the means’, for example, thatindividual human rights can be sacrificed to attain asocial goal. Moreover, consequentialists have beenunable to agree on which outcomes should bedecisive for evaluating decisions and behaviour.

• Principlism, as its name implies, uses ethicalprinciples as the basis for making moral decisions. Itapplies these principles to particular cases orsituations in order to determine what is the rightthing to do, taking into account both rules andconsequences. Principlism has been extremely

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38influential in recent ethical debates, especially in theUSA. Four principles in particular, respect forautonomy, beneficence, non-maleficence andjustice, have been identified as the most importantfor ethical decision making in health care. Principlesdo indeed play an important role in rational decisionmaking. However, the choice of these fourprinciples, and especially the prioritisation of respectfor autonomy over the others, is a reflection ofWestern liberal culture and is not necessarilyuniversal. Moreover, these four principles oftenclash in particular situations and there is need forsome criteria or process for resolving such conflicts.

• Virtue ethics focuses less on decision making andmore on the character of decision makers asreflected in their behaviour. A virtue is a type ofmoral excellence or competence. As noted above,one virtue that is especially important for dentists iscompassion. Others include honesty, prudence anddedication. Dentists who possess these virtues aremore likely to make good decisions and toimplement them in a good way. However, evenvirtuous individuals often are unsure how to act inparticular situations and are not immune frommaking wrong decisions.

None of these four approaches, or others that havebeen proposed, has been able to win universalassent. This can be explained partly by the fact thateach approach has both strengths and weaknesses.Ethical theories are similar to scientific theories in thatthey are all plausible but some are eventually provensuperior to the others. Moreover, individuals differamong themselves in their preference for a rationalapproach to ethical decision making just as they do in


39their preference for a non-rational approach.However, to the extent that principlism takes intoaccount both rules and consequences, it may be themost helpful for making clinical ethical decisions atthe chairside, as long as all the relevant rules andconsequences are considered. Virtue ethics isespecially important for ensuring that the behaviourof the decision maker both in coming to a decisionand in implementing it is admirable. What does all this mean in practice? When facedwith a problem for which there is no obvious answer,a dentist can use one of the following algorithms:

1. DECIDE

• Determine whether the issue at hand is an ethical one.

• Educate yourself about authoritative sources such asdental association codes of ethics and policies andconsult respected colleagues to see how dentistsgenerally deal with such issues.

• Consider alternative solutions in light of theprinciples and values they uphold and their likelyconsequences.

• Inform those whom your proposed solution willaffect and discuss it with them.

• Make your Decision and act on it, with sensitivity toothers affected.

• Evaluate your decision and be prepared to actdifferently in future.

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402. ACD

Assess

• Is it true?

• Is it accurate?

• Is it fair?

• Is it quality?

• Is it legal?

Communicate

• Have you listened?

• Have you informed the patient?

• Have you explained outcomes?

• Have you presented alternatives?

Decide

• Is now the best time?

• Is it within your ability?

• Is it in the best interests of the patient?

• Is it what you would want for yourself?


41ConclusionThis chapter sets the stage for what follows. Whendealing with specific issues in dental ethics, it is goodto keep in mind that dentists have faced many of thesame issues in the past and that their accumulatedexperience and wisdom can be very valuable today.The FDI and other dental organisations carry on thistradition and provide much helpful ethical guidanceto dentists. However, despite a large measure ofconsensus among dentists on ethical issues,individuals can and do disagree on how to deal withspecific cases. Moreover, the views of dentists can bequite different from those of patients and of otherhealth care providers. As a first step in resolvingethical conflicts, it is important for dentists tounderstand different approaches to ethical decisionmaking, including their own and those of the peoplewith whom they are interacting. This will help themdetermine for themselves the best way to act and toexplain their decisions to others.

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42CHAPTER TWO – DENTISTS AND PATIENTS

Objectives

After working through this chapter you should beable to:

• explain why all patients are deserving of respect andequal treatment;

• identify the essential elements of informed consent;

• explain how treatment decisions should be madefor children and for patients who are incapable ofmaking their own decisions;

• explain the justification for patient confidentialityand recognise legitimate exceptions toconfidentiality;

• understand your ethical obligations towardsuncooperative patients;

• consider how to deal with patients who cannotafford needed oral health care.

Case Study #1Dr. P has been in practice for 32 years. His olderpatients appreciate his devoted service and aregenerally quite happy to let him decide whattreatment they will have. Some of his youngerpatients, on the other hand, resent what theyconsider to be his paternalistic approach and the lackof information about treatment options. When CaroleJ, a 28-year-old accountant, asks Dr. P for a referral toan orthodontist to correct a mild overbite, Dr. Prefuses because it is his professional opinion that thetreatment is unnecessary. He is willing to lose a


43patient rather than compromise with his principle thatdentists should only provide beneficial treatments topatients. He will neither mention nor refer patientsfor treatments that he considers unnecessary orharmful.

What’s Special About the Dentist-PatientRelationship?The dentist-patient relationship is the cornerstone ofdental practice and therefore of dental ethics. Asnoted above, the International Principles of Ethicsfor the Dental Profession states, “The needs of thepatient are the overriding concern….” As discussed inChapter One, the traditional interpretation of thedentist-patient relationship as a paternalistic one, inwhich the dentist made the decisions and the patientsubmitted to them, has been widely rejected in recentyears, both in ethics and in law, in favour of an equalpartnership. However, since many patients are eitherunable or unwilling to make decisions about theirdental care, patient autonomy is often veryproblematic. Equally problematic are other aspects ofthe relationship, such as the dentist’s obligation tomaintain patient confidentiality in an era ofcomputerised dental records and demands fromagencies with competing interests for access topatient data, and the provision of treatment topatients who cannot afford it. This section will dealwith six topics that pose particularly challengingproblems to dentists in their daily practice: respectand equal treatment; communication and consent;decision-making for incompetent patients;confidentiality; uncooperative patients; and financialrestraints on treatment. .

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44Respect and Equal Treatment The belief that all human beings deserve respect andequal treatment is relatively recent. In most societiesdisrespectful and unequal treatment of individualsand groups used to be regarded as normal andnatural. Slavery was one such practice that was noteradicated in the European colonies and the USAuntil the 19th century and, though illegal, it still existsin some parts of the world. Women still experiencelack of respect and unequal treatment in manycountries. Discrimination on the basis of race, age,disability or sexual orientation is widespread. Clearly,there remains considerable resistance to the claimthat all people should be treated as equals.

The gradual and still ongoing conversion of humanityto a belief in human equality began in the 17th and18th centuries in Europe and North America. It wasled by two opposed ideologies: a new interpretationof Christian faith and an anti-Christian rationalism.The former inspired the American Revolution and Billof Rights; the latter, the French Revolution andrelated political developments. Under these twoinfluences, democracy very gradually took hold andbegan to spread throughout the world. It was basedon a belief in the political equality of all men (and,much later, women) and the consequent right to havea say in who should govern them.

In the 20th century there was considerableelaboration of the concept of human equality interms of human rights. One of the first acts of thenewly established United Nations was to develop theUniversal Declaration of Human Rights (1948),which states in article 1, “All human beings are bornfree and equal in dignity and rights.” Many other


45international and national bodies have producedstatements of rights, either for all human beings, forall citizens in a specific country, or for certain groupsof individuals (‘children’s rights’, ‘patients’ rights’,‘consumers’ rights’, etc.). Numerous organisationshave been formed to promote action on thesestatements. Unfortunately, though, human rights arestill not respected in many countries.

The dental profession has had somewhat conflictingviews on patient equality and rights over the years.On the one hand, dentists have been told not to“refuse to accept patients into their practice or denydental service to patients because of the patient’srace, creed, color, sex or national origin” (AmericanDental Association: Principles of Ethics and Codeof Professional Conduct). At the same time the FDIInternational Principles of Ethics for the DentalProfession asserts the dentist’s right “to decline totreat a patient, except for the provision of emergencycare, for humanitarian reasons, or where the laws ofthe country dictate otherwise.” Although thelegitimate grounds for such refusal include a fullpractice, (lack of) educational qualifications andspecialisation, if dentists do not have to give anyreason for refusing a patient, they can easily practisediscrimination without being held accountable. Adentist’s conscience, rather than the law ordisciplinary authorities, may be the only means ofpreventing abuses of human rights in this regard.

Even if dentists do not offend against respect andhuman equality in their choice of patients, they canstill do so in their attitudes towards and treatment ofpatients. As noted in Chapter One, compassion is oneof the core values of dentistry and is an essential

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46element of a good therapeutic relationship.Compassion is based on respect for the patient’sdignity and values but goes further in acknowledgingand responding to the patient’s vulnerability in theface of illness and/or disability. If patients sense thedentist’s compassion, they will be more likely to trustthe dentist to act in their best interests, and this trustcan contribute to the healing process.

In order to safeguard the trust that is essential to thedentist-patient relationship, dentists should notabandon patients whose care they have undertaken.The American Dental Association’s Principles ofEthics and Code of Professional Conduct states:“Once a dentist has undertaken a course oftreatment, the dentist should not discontinue thattreatment without giving the patient adequate noticeand the opportunity to obtain the services of anotherdentist. Care should be taken that the patient’s oralhealth is not jeopardised in the process.”

There are many reasons for a dentist wanting toterminate a relationship with a patient, for example,the dentist’s moving or stopping practice, thepatient’s refusal or inability to pay for the dentist’sservices, dislike of the patient and the dentist foreach other, the patient’s refusal to comply with thedentist’s recommendations, etc. The reasons may beentirely legitimate, or they may be unethical. Whenconsidering such an action, dentists should consulttheir Code of Ethics and other relevant guidancedocuments and carefully examine their motives. Theyshould be prepared to justify their decision to thepatient and to a third party if appropriate. If themotive is legitimate, the dentist should help thepatient find another suitable dentist or, if this is not


47possible, should give the patient adequate notice ofwithdrawal of services so that the patient can findalternative dental care. If the motive is not legitimate,for example, racial prejudice, the dentist should takesteps to deal with this defect.

Many dentists, especially those in the public sector,often have no choice of the patients they treat. Somepatients are violent and pose a threat to the safety ofthe dentist or the office staff. Others can only bedescribed as obnoxious because of their antisocialattitudes and behaviour. Have such patients forsakentheir right to respect and equal treatment, or aredentists expected to make extra, perhaps even heroic,efforts to establish and maintain therapeuticrelationships with them? With such patients, dentistsmust balance their responsibility for their own safetyand well-being and that of their staff with their dutyto promote the well-being of the patients. Theyshould attempt to find ways to honour both of theseobligations. If this is not possible, they should try tomake alternative arrangements for the care of thepatients.

Another challenge to the principle of respect andequal treatment for all patients arises in the care ofinfectious patients. The focus in this respect is oftenon HIV/AIDS, not only because it is a life-threateningdisease but also because it is associated with socialprejudices. However, there are many other seriousinfections including some that are more easilytransmissible to health care providers than HIV/AIDS.Some dentists hesitate to perform invasive procedureson patients with such conditions because of thepossibility that they, the dentists, might becomeinfected. However, dental codes of ethics make no

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48exception for infectious patients with regard to thedentist’s duty to treat all patients equally. Accordingto the FDI’s Policy Statement on Human Immunodeficiency Virus Infection and OtherBlood Borne Infections, “Patients with HIV andother blood borne infections should not be deniedoral health care solely because of their infections.”The Statement recommends that “universal infectioncontrol procedures should be employed for allpatients irrespective of their health status” in order toprevent transmission of infectious diseases frompatients to dentists or other oral health care providersor from them to patients.

The intimate nature of the dentist-patient relationshipcan give rise to sexual attraction. A fundamental ruleof traditional medical ethics, equally applicable todentists, is that such attraction must be resisted. TheOath of Hippocrates includes the following promise:“Whatever houses I may visit, I will come for thebenefit of the sick, remaining free of all intentionalinjustice, of all mischief and in particular of sexualrelations with both female and male persons….” Inrecent years some dental associations have restatedthis prohibition of sexual relations between dentistsand their patients. The reasons for this are as validtoday as they were in Hippocrates’ time, 2500 yearsago. Patients are vulnerable and put their trust indentists to treat them well. They may feel unable toresist sexual advances of dentists for fear that theywill not receive needed dental treatment. Moreover,the clinical judgment of a dentist can be adverselyaffected by emotional involvement with a patient. This latter reason applies as well to dentists treatingtheir family members. However, the application ofthis principle can vary according to circumstances. For


49example, solo practitioners working in remote areasmay have to provide dental care for their familymembers, especially in emergency situations.

Communication and ConsentInformed consent is one of the central concepts ofpresent-day dental ethics. The right of patients tomake decisions about their health care has beenenshrined in legal and ethical statements throughoutthe world. As noted in Chapter One, the U.K.General Dental Council advises dentists that: “It is ageneral legal and ethical principle that you must getvalid consent before starting treatment or physicalinvestigation, or providing personal care, for apatient. This principle reflects the right of patients todetermine what happens to their own bodies, and isa fundamental part of good practice”.

A necessary condition for informed consent is goodcommunication between dentist and patient. Whendental paternalism was normal, communication wasrelatively simple; it consisted of dentists telling theirpatients what treatment they were going to perform.Nowadays communication requires much more ofdentists. They must provide all the informationpatients need to make their decisions. This involvesexplaining complex dental diagnoses, prognoses andtreatment regimes in simple language, confirming orcorrecting information that the patients may haveobtained elsewhere (e.g., from another healthpractitioner, magazines or the Internet), ensuring thatpatients understand the treatment options (includingthe option of no treatment) and the costs,advantages and disadvantages of each, answeringany questions they may have, and understandingwhatever decision the patient has reached and, if

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50possible, the reasons for it. Good communicationskills do not come naturally to most people; theymust be developed and maintained with consciouseffort and periodic review.

Three major obstacles to good dentist-patientcommunication are differences of language andculture and patient speech impairment duringtreatment. If the dentist and the patient do not speakthe same language, an interpreter will be required. Inmany settings there are no qualified interpreters andthe dentist must rely on family members or seeksomeone else for the task. Culture, which includesbut is much broader than language, can raiseadditional communication issues. Because of differentcultural understandings of the nature and causes ofillness, patients may not understand the diagnosisand treatment options provided by dentists.Moreover, what is considered a disfigurement in oneculture may be a sign of beauty in another. In suchcircumstances dentists should make every reasonableeffort to probe their patients’ understanding of healthand healing and communicate their recommendationsto the patients as best they can. During treatmentpatients may well be unable to talk, thus significantlyreducing their decision making ability. For this reasonpatients should be fully informed, in advance, of allrelevant information about their treatment anddentists should take steps to facilitate two-waycommunication during treatment, for example, byproviding a writing tablet for patients to ask andanswer questions.

If the dentist has successfully communicated to thepatient all the information the patient needs andwants to know about his or her diagnosis, prognosis


51and treatment options, the patient will then be in aposition to make an informed decision about how toproceed. Although the term ‘consent’ impliesagreement to treatment, the concept of informedconsent applies equally to refusal of treatment or tochoice among alternative treatments. Competentpatients have the right to refuse treatment, evenwhen the refusal will result in pain or disability.

Evidence of consent can be explicit or implicit(implied). Explicit consent is given orally or in writing.Consent is implied when the patient indicates awillingness to undergo a certain procedure ortreatment by his or her behaviour. For example,consent for an oral examination is implied by the action of opening one’s mouth. For treatmentsthat entail risk or involve more than mild discomfort,it is preferable to obtain explicit rather than implied consent.

There are two exceptions to the requirement forinformed consent by competent patients:

• Situations where patients voluntarily give over theirdecision-making authority to the dentist or to athird party. Because of the complexity of the matteror because the patient has complete confidence inthe dentist’s judgement, the patient may tell thedentist, “Do what you think is best.” Dentistsshould not be eager to act on such requests butshould provide patients with basic informationabout the treatment options and encourage themto make their own decisions. However, if after suchencouragement the patient still wants the dentist todecide, the dentist should do so according to thebest interests of the patient.

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• Instances where the disclosure of information wouldcause harm to the patient. The traditional conceptof ‘therapeutic privilege’ is invoked in such cases; itallows dentists to withhold dental information ifdisclosure would be likely to result in seriousphysical, psychological or emotional harm to thepatient, for example, if the patient would be likelyto forgo needed treatment if it will be painful. Thisprivilege is open to great abuse and dentists shouldonly make use of it in extreme circumstances. Theyshould start with the expectation that all patientsare able to cope with the facts and reservenondisclosure for cases in which they are convincedthat more harm will result from telling the truththan from not telling it. Outright lying, however, isnever justified since it does serious harm to the trustrelationship of patient and dentist.

In keeping with the growing trend towardsconsidering health care as a consumer product andpatients as consumers, patients and their families notinfrequently demand access to dental services that, inthe considered opinion of dentists, are eithersubstandard or unnecessary. The case described atthe beginning of the chapter is an example of thistrend. Dentists need to consider such requestscarefully and ensure that, on the one hand, they donot act unprofessionally by providing substandardtreatment or by wasting scarce health care resources.On the other hand, they must guard against imposingtheir personal values on their patients and alwaysbase their treatment recommendations on currentprofessional practice standards. Here, again, goodcommunication between dentists and patients isessential for understanding and evaluating the


53reasons that patients may have for their treatmentpreferences.

Decision-making for incompetent patientsMany patients are not competent to make decisionsfor themselves. Examples include young children andindividuals affected by certain psychiatric orneurological conditions such as dementia. Thesepatients require substitute decision-makers, either thedentist or another person. Ethical issues arise in thedetermination of whether or not the patient iscompetent to make decisions and, if not, of theappropriate substitute decision-maker and in thechoice of criteria for decisions on behalf ofincompetent patients.

When dental paternalism prevailed, the dentist wasconsidered to be the appropriate decision-maker forincompetent patients. Dentists might consult withparents or other family members about treatmentoptions, but the final decisions were theirs to make.Dentists have been gradually losing this authority inmany countries as patients are given the opportunityto name their own substitute decision-makers to actfor them when they become incompetent. Inaddition, some jurisdictions specify the appropriatesubstitute decision-makers in descending order (e.g.,for children, the parents, grandparents, etc.; foradults, husband or wife, adult children, brothers andsisters, etc.). In such cases dentists make decisions forpatients only when the designated substitute cannotbe found.

Problems arise when those claiming to be theappropriate substitute decision-makers, for exampledivorced parents, do not agree among themselves or

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54when they do agree, their decision is, in the dentist’sopinion, not in the patient’s best interests. In the firstinstance the dentist can attempt to mediate betweenthe parties. If this fails, as well as in cases of seriousdisagreement between the substitute decision-maker(s) and the dentist, the dentist may have tochallenge the decision in the relevant legal institution.The principles and procedures for informed consentthat were discussed in the previous section are justas applicable to substitute decision-making as topatients making their own decisions. Dentists havethe same duty to provide all the information thesubstitute decision-makers need to make theirdecisions.

The principal criteria to be used for treatmentdecisions for children and mentally disabled adults aretheir best interests, although their expressedpreferences should be honoured to the greatestextent possible compatible with their best interests.For adult patients who have become incompetent,the principal criteria are their preferences, if these areknown. If these are not known, treatment decisionsshould be based on the patients’ best interests.

Competence to make decisions about one’s oralhealth care can be difficult to assess, especially inadolescents and those whose capacity for reasoninghas been impaired by acute or chronic illness. Aperson may be competent to make decisionsregarding some aspects of life but not others; as well,competence can be intermittent — a person may berational at certain times of the day and not at others.Although such patients may not be legallycompetent, their preferences should be taken intoaccount when decisions are being made for them.


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Not infrequently, patients are unable to make areasoned, well thought-out decision regardingdifferent treatment options due to the discomfort anddistraction caused by their disease. However, theymay still be able to indicate their rejection of aspecific intervention, for example, by refusing to opentheir mouth. In such cases, these expressions ofdissent should be taken very seriously, although theyneed to be considered in light of the overall goals oftheir treatment plan.

In all instances, dentists must keep in mind that apatient’s refusal of a recommended treatment doesnot mean that the patient is incompetent; it may bethat the patient has failed fully to understand thedentist’s recommendation and the reasons for it.Likewise, patients are not necessarily competentbecause they readily agree to the dentist’s proposedtreatment. Refusing patients may well be competentwhereas agreeing patients may well be incompetent,thus making their agreement invalid.

ConfidentialityThe duty to keep patient information confidential hasbeen a cornerstone of medical ethics since the timeof Hippocrates. The Hippocratic Oath states: “What Imay see or hear in the course of the treatment oreven outside of the treatment in regard to the life ofmen, which on no account one must spread abroad, Iwill keep to myself holding such things shameful tobe spoken about.” This duty is central to dentalethics as well. For example, the FDI’s InternationalPrinciples of Ethics for the Dental Professionrequires that the professional dentist “must ensureprofessional confidentiality of all information about

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56patients and their treatment.” However, the duty ofconfidentiality is not absolute. The possibility thatbreaches of confidentiality are sometimes justifiedcalls for clarification of the very idea of confidentiality.

The high value that is placed on confidentiality hasthree sources: autonomy, respect for others and trust.

Autonomy relates to confidentiality in that personalinformation about an individual belongs to him or herand should not be made known to others without hisor her consent. When an individual chooses to revealspersonal information to another, a dentist, dentalhygienist or nurse for example, or when informationcomes to light through a dental test, those in theknow are bound to keep it confidential unless theindividual concerned allows them to divulge it.

Confidentiality is also important because humanbeings deserve respect. One important way ofshowing them respect is by preserving their privacy. Inthe dental setting, privacy is often greatlycompromised, but this is all the more reason toprevent further unnecessary intrusions into a person’sprivate life. Since individuals differ regarding theirdesire for privacy, we cannot assume that everyonewants to be treated as we would want to be. Caremust be taken to determine which personalinformation a patient wants to keep secret and whichhe or she is willing to have revealed to others.

Trust is an essential part of the dentist-patientrelationship. In order to receive dental care, patientshave to reveal personal information to dentists andothers who may be total strangers to them—information that they would not want anyone else to


57know. They must have good reason to trust theircaregivers not to divulge this information. The basisof this trust is the ethical and legal standards ofconfidentiality that health care professionals areexpected to uphold. Without an understanding that their disclosures will be kept secret, patients may withhold personal information. This can hinder dentists in their efforts to provide effective interventions.

The U.K. General Dental Council’s Principles ofPatient Confidentiality summarises the dentist’sresponsibilities for respecting confidentiality asfollows:

• Treat information about patients as confidential andonly use it for the purposes for which it is given.

• Prevent information from being accidentallyrevealed and prevent unauthorised access bykeeping information secure at all times.

• In exceptional circumstances, it may be justified tomake confidential patient information knownwithout consent if it is in the public interest or thepatient’s interest.

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58As this guidance document states, there areexceptions to the requirement to maintainconfidentiality. Some of these are relatively non-problematic; others raise very difficult ethical issuesfor dentists.

Some breaches of confidentiality occur frequently inhealth care settings. Individuals other than dentists—dental assistants, receptionists, etc.—require access toa patient’s health records in order for the patient tobe provided adequate care. Where patients speak adifferent language than their dentists, there is a needfor interpreters to facilitate communication. In casesof patients who are not competent to make theirown dental decisions, other individuals have to begiven information about them in order to makedecisions on their behalf and to provide follow-upcare for them. These breaches of confidentiality areusually justified, but they should be kept to aminimum and those who gain access to confidentialinformation should be made aware of the need notto spread it any further than is necessary for thepatient’s benefit. As the FDI’s InternationalPrinciples of Ethics for the Dental Professionstates, “The dentist must ensure that all staff respectpatients confidentiality except where the laws of thecountry dictate otherwise.” Normally, patients shouldbe informed that such breaches of confidentiality willoccur and that the duty of confidentiality applies tothose who have access to the patients’ information.

Another generally accepted reason for breachingconfidentiality is to comply with legal requirements.For example, many jurisdictions have laws for themandatory reporting of suspected child abuse.Dentists should be aware of the legal requirements


59for the disclosure of patient information where theywork. However, legal requirements can conflict withthe respect for human rights that underlies dentalethics. Therefore, dentists should view with a criticaleye any legal requirement to breach confidentialityand assure themselves that it is justified beforeadhering to it.

If dentists are persuaded to comply with legalrequirements to disclose their patients’ dentalinformation, it is desirable that they discuss with thepatients or guardians the necessity of any disclosurebefore it occurs and enlist their co-operation. Forexample, it is preferable that a parent suspected ofchild abuse call the child protection authorities in thedentist’s presence to self-report, or that the dentistobtain the parent’s consent before the authorities arenotified. This approach will prepare the way forsubsequent interventions. If such co-operation is notforthcoming and the dentist has reason to believethat any delay in notification may put a child at riskof further harm, then the dentist ought toimmediately notify child protection authorities andsubsequently inform the parent or guardian that thishas been done.

In the case of an HIV-positive patient, disclosure to aspouse or current sexual partner may not be unethicaland, indeed, may be justified when the patient isunwilling to inform the person(s) at risk. Suchdisclosure requires that all of the following conditionsare met: the partner is at risk of infection with HIVand has no other reasonable means of knowing therisk; the patient has refused to inform his or hersexual partner; the patient has refused an offer ofassistance by the dentist to do so on the patient’s

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60behalf; and the dentist has informed the patient ofhis or her intention to disclose the information to thepartner. When considering how to proceed in suchcircumstances, the dentist is advised to seekappropriate legal advice and to consult with thepatient’s physician.

Dealing with uncooperative patientsAs every practising dentist knows, some patients arevery difficult to treat, not because of their oral healthstatus but because of their attitudes or behaviour. TheFDI International Principles of Ethics for theDental Profession requirement that “The needs ofthe patient are the overriding concern” may seemimpossible to fulfil when the patient refuses tocooperate. Two categories of such patients are fearfulchildren and noncompliant adults.

There are many reasons why some children resistdental diagnosis and treatment. Some of these areirrational, such as a belief that any dental treatmentnecessarily involves excruciating pain. Others arecompletely rational, for example, a dentist maypreviously have told the child that “this won’t hurt abit” when it fact he did cause the child pain.Whatever the reasons, good communication with thepatient is the key to overcoming resistance. Suchcommunication has to take into account the child’sage and ability to understand what is involved indiagnosis and treatment, as well as any badexperiences the child may have had with dentaltreatment. In some cases, referral to a paediatricdentist may be advisable.

It is likely that relatively few patients are fullycompliant with the recommendations of their dentist


61for both self care and continuing professional care.Continuing the care of mildly noncompliant patientsposes no serious ethical issues for dentists. However,there are some patients whose blatant disregard fortheir oral health seriously compromises the efforts oftheir dentists to care for them. They may neglect tobrush their teeth or they may cancel follow-upappointments and then return later with advancedoral diseases. Some dentists may consider thetreatment of such patients a waste of their time anddecide to terminate the professional relationship withthem. As noted above, dental ethics does allow forsuch termination under certain conditions: the dentistshould have made reasonable efforts to encourage achange of behaviour on the part of the patient,including a gentle warning that if there is no suchchange, the patient may have to find another dentist;the dentist should be prepared to justify his/herdecision to the patient and to a third party ifappropriate; the dentist should help the patient findanother suitable dentist or, if this is not possible,should give the patient adequate notice ofwithdrawal of services so that the patient can findalternative dental care.

Financial restraints on treatmentIn contrast to medical care, which is widely regardedas a basic human right, oral health care receivesrelatively little financial support from governments.Consequently, the costs of dental services are often amore pressing issue for patients, even in wealthycountries, than the costs of medical care. In lowerand middle income countries, the acute shortage ofdentists compounds the problem of access to oralhealth care.

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62In most countries, the vast majority of dentists areprivate practitioners. They have to ensure the financialviability of their practice while remaining faithful tothe ethical foundations of their profession. Fulfillingboth these obligations is often very difficult, especiallywhen patients cannot afford needed dentaltreatment. In such situations, the requirement of theFDI International Principles of Ethics for theDental Profession that “The needs of the patientare the overriding concern” clashes with the financialreality that dental services cannot be provided free ofcharge to everyone in need.

The more general problem of access to oral healthcare will be treated in the next chapter. Here thediscussion will be limited to the responsibilities ofindividual dentists towards their patients who do nothave sufficient means, either through insurance ortheir personal assets, to pay for needed dental care.Although dentists are generally not required, eitherby law or by professional regulations, to provide careto those who cannot afford it, except in anemergency, their membership in a recognisedhealthcare profession entails a responsibility toconsider how they can meet the dental needs of atleast some of these patients. Ways of doing thisinclude the following:

• accepting patients covered by insurance thatprovides compensation below the rate usuallycharged by the dentist;

• allowing patients to pay over an extended period;

• reducing or eliminating fees for some patients;


63• lobbying for better oral health insurance coverage

for those in need.

The amount of charity care expected from dentistscannot be quantified, since they differ greatly withregard to their financial circumstances. Asprofessionals concerned with the welfare of theirpatients, however, they will want to consider howthey can make their services available to people whocannot afford them.

Back to the Case StudyAccording to the analysis of the dentist-patientrelationship presented in this chapter, Dr. P’s conductis ethically questionable. He is clearly a man ofprinciple, which is to be admired. However, hisconviction that his principles should take precedenceover those of his patients is contrary to the growinglegal and ethical consensus that patients have theright to make decisions about their health care. If Dr.P is genuinely concerned about the harmfulconsequences of orthodontic treatment for thispatient, rather than bluntly refusing to refer heshould begin by explaining his concerns to thepatient. If for professional or conscience reasons adentist refuses to provide a particular service, it doesnot automatically follow that he or she should notrefer the patient to another dentist. Although the FDIInternational Principles of Ethics for the DentalProfession requires referrals only “for advice and/ortreatment …requiring a level of competence beyondthat held”, respect for the patient’s autonomy wouldseem to require the dentist at the very least to assistthe patient in finding another dentist who wouldconsider her request. Given the rapid progress ofdental technology, the different values that individuals

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64attach to facial appearance, and the lack ofagreement among dentists on practice standards, adentist should not be too certain that his or heroutlook is the only right one, or even the best one.


65CHAPTER THREE – DENTISTS AND SOCIETY

Objectives

After working through this chapter you should beable to:

• recognise conflicts between the dentist’s obligationsto patients and obligations to society and identifythe reasons for the conflicts

• identify and deal with the ethical issues involved inallocating scarce dental resources

• recognise dentist responsibilities for public andglobal health.

Case Study #2Dr. S is one of only two dentists in her community.Between them they have just managed to providebasic oral care to the population. Recently hercolleague has changed his practice to focus ontechnically and aesthetically advanced services thatonly adequately insured or middle and upper classpatients can afford. As a result, Dr. S is overwhelmedby patients requiring basic care. She is reluctant toration her services but feels that she has no choice.She wonders what is the fairest way to do so: byfavouring her previous patients over those of hercolleague; by giving priority to emergency cases; byestablishing a waiting list so that all will get treatedeventually; or by some other way.

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66What’s Special About the Dentist-Society Relationship?Dentistry is a profession. The term ‘profession’ hastwo distinct, although closely related, meanings: (1)an occupation that is characterised by dedication tothe well-being of others, high moral standards, abody of knowledge and skills, and a high level ofautonomy; and (2) all the individuals who practisethat occupation. ‘The dental profession’ can meaneither the practice of dentistry or dentists in general.

Dental professionalism involves not just therelationship between a dentist and a patient, asdiscussed in Chapter Two, and relationships withcolleagues and other health professionals, which willbe treated in Chapter Four. It also involves arelationship with society. This relationship can becharacterised as a ‘social contract’ whereby societygrants the profession privileges, including exclusive orprimary responsibility for the provision of certainservices and a high degree of self-regulation, and inreturn, the profession agrees to use these privilegesmainly for the benefit of others and only secondarilyfor its own benefit.

Although most dentists may consider themselves first and foremost as private practitioners, dentistry isin fact both a social and an individual activity. It takes place in a context of government and corporate regulation and funding. It relies onacademic and corporate dental research and product development for its knowledge base andtreatments. It treats diseases that are as much socialas biological in origin.


67The Hippocratic background of dental ethics has littleguidance to offer with regard to relationships withsociety. To supplement this approach, present-daydental ethics addresses the issues that arise beyondthe individual patient-dentist relationship andprovides criteria and processes for dealing with these issues.

To speak of the ‘social’ character of dentistryimmediately raises the question – what is society? Inthis Manual the term refers to a community ornation. It is not synonymous with government;governments should, but often do not, represent theinterests of society, but even when they do, they areacting for society, not as society.

Dentists have various relationships with society.Because society, and its physical environment, aresignificant factors in the health of patients, both thedental profession in general and individual dentistshave important roles to play in public health, healtheducation, environmental protection, laws affectingthe health or well-being of the community, andtestimony at judicial proceedings. Dentists are alsocalled upon to play a role in the allocation of society’sscarce healthcare resources, and sometimes they havea duty to prevent patients from accessing services towhich they are not entitled. Implementing theseresponsibilities can raise ethical conflicts, especiallywhen the interests of society seem to conflict withthose of individual patients. Moreover, dentistry’srelationships with society are evolving and needregular review to ensure that the needs of thecommunity are met.

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68Dual LoyaltyWhen dentists have responsibilities and areaccountable both to their patients and to a thirdparty and when these responsibilities andaccountabilities are incompatible, they findthemselves in a situation of conflict of interests or‘dual loyalty’. Third parties that demand dentists’loyalty include governments, employers (e.g.,hospitals and managed health care organisations),insurers, military officials, police, prison officials andfamily members. Where the FDI InternationalPrinciples of Ethics for the Dental Professionstates that “The needs of the patient are theoverriding concern,” that is, not the only concern, itimplies that dentists may in exceptional situationshave to place the interests of others above those ofthe patient. The ethical challenge is to decide whenand how to protect the patient in the face ofpressures from third parties.

Dual loyalty situations comprise a spectrum rangingfrom those where society’s interests should takeprecedence to those where the patient’s interests are clearly paramount. In between is a large grey area where the right course of action requiresconsiderable discernment.

At one end of the spectrum are requirements formandatory reporting of patients who suffer fromdesignated infectious diseases or those suspected ofchild abuse. Dentists should fulfil these requirementswithout hesitation, although patients should normallybe informed that such reporting will take place.At the other end of the spectrum are requests ororders by the policy or military to take part inpractices that violate fundamental human rights, such


69as torture. In such situations, dentists should fulfiltheir professional responsibility to determine the bestinterests of the patient and should observe, as far aspossible, the normal ethical requirements of informed consent and confidentiality. Any breach ofthese requirements must be justified and must bedisclosed to the patient. Dentists should report to the appropriate authorities any unjustifiedinterference in the care of their patients, especially iffundamental human rights are being denied. If theauthorities are unresponsive, help may be availablefrom a national dental association, the FDI andhuman rights organisations.

Closer to the middle of the spectrum are the practicesof some managed health care programmes that limitthe clinical autonomy of dentists to determine howtheir patients should be treated. Although suchpractices are not necessarily contrary to the bestinterests of patients, they can be, and dentists needto consider carefully whether they should participatein such programmes. If they have no choice in thematter, for example, where there are no alternativeprogrammes, they should advocate vigorously fortheir own patients and, through their dentalassociations, for the needs of all the patients affectedby such restrictive policies.

A particular form of a dual loyalty issue faced bydentists is the potential or actual conflict of interestbetween a commercial organisation on the one handand patients and/or society on the other.Pharmaceutical companies, manufacturers of dentaldevices and supplies and other commercialorganisations not infrequently offer dentists gifts andother benefits that range from free samples to travel

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70and accommodation at educational events toexcessive remuneration for research activities (seeChapter Five). A common underlying motive for suchcompany largesse is to convince the dentist to use orprescribe the company’s products, which may not bethe best ones for the dentist’s patients and/or mayadd unnecessarily to a society’s health costs. Theprimary ethical principle for dealing with suchsituations is that dentists should resolve any conflictbetween their own interests and those of theirpatients in their patients’ favour. More specifically,dentists are well advised to follow the advice of theAmerican Dental Association’s Principles of Ethicsand Code of Professional Conduct where it states:“In the case of a health-related product, it is notenough for the dentist to rely on the manufacturer’sor distributor’s representations about the product’ssafety and efficacy. The dentist has an independentobligation to inquire into the truth and accuracy ofsuch claims and verify that they are founded onaccepted scientific knowledge or research.”

Resource allocationIn every country in the world, including the richest ones, there is an already wide and steadilyincreasing gap between the needs and desires forhealthcare services and the availability of resources toprovide these services. The existence of this gaprequires that the existing resources be rationed insome manner. Healthcare rationing, or ‘resourceallocation’ as it is more commonly referred to, takesplace at three levels:

• At the highest (‘macro’) level, governments decidehow much of the overall budget should beallocated to health; which healthcare expenses will


71be provided at no charge and which will requirepayment either directly from patients or from theirinsurance plans; within the health budget, howmuch will go to remuneration for heath careworkers, to capital and operating expenses forhospitals and other institutions, to research, toeducation of health professionals, to treatment ofspecific conditions such as tuberculosis or AIDS, and so on.

• At the institutional (‘meso’) level, which includeshospitals, clinics, healthcare agencies, and dentists’offices, authorities decide how to allocate theirresources: which services to provide; how much tospend on staff, equipment, security, other operatingexpenses, renovations, expansion, etc.

• At the individual patient (‘micro’) level, dentistsdecide whether and how often radiographic testsshould be performed, whether to recommendsimple or more complex treatment, whether areferral to another dentist is needed, etc. Despitethe growing encroachment of managed care,dentists have considerable discretion as to whichresources their patients will have access.

The choices that are made at each level have a majorethical component, since they are based on valuesand have significant consequences for the health andwell-being of individuals and communities. Individualdentists are involved in decisions at all levels.

As noted above, dentists are expected to act primarilyin the interests of their own patients. Their coreethical values of compassion, competence andautonomy are directed towards serving the needs of

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72their own patients. This individualistic approach todental ethics has survived the transition from dentistpaternalism to patient autonomy, where the will ofthe individual patient is the main criterion fordeciding what resources he or she should receive.However, another value, justice, is becoming animportant factor in dental decision-making. It entailsa more social approach to the distribution ofresources, one that considers the needs of otherpatients. According to this approach, dentists areresponsible not just for their own patients but, to acertain extent, for others as well.

This new understanding of the dentist’s responsibilityto society is reflected in the FDI InternationalPrinciples of Ethics for the Dental Professionwhere it states: “The dentist should…support andpromote accepted measures to improve the oralhealth of the public.” One way that dentists canexercise this responsibility insofar as it involves theallocation of resources is by avoiding wasteful andinefficient practices, even when patients requestthem. Clinical practice guidelines are available forsome dental conditions; they help to distinguishbetween effective and ineffective treatments. Dentistsshould familiarise themselves with these guidelines,both to conserve resources and to provide optimaltreatment to their patients.

A type of allocation decision that almost all dentistsmust make is the choice among patients who are inneed of their care, including those who cannot affordto pay for needed treatment. Dentists must decidewhich patients will have access to their services andwhich will not, knowing full well that those who aredenied may suffer as a result.


73In dealing with these allocation issues, dentists mustnot only balance the principles of compassion andjustice but, in doing so, must decide which approachto justice is preferable. There are several suchapproaches, including the following:

• libertarian — resources should be distributedaccording to market principles (individual choiceconditioned by ability and willingness to pay, withlimited charity care for the destitute);

• utilitarian — resources should be distributedaccording to the principle of maximum benefit for all;

• egalitarian — resources should be distributedstrictly according to need;

• restorative — resources should be distributed so asto favour the historically disadvantaged.

Unlike medicine, dentistry has traditionally favouredthe libertarian approach, which has also beenaccepted by many governments for whom oral healthcare is a very low priority. However, the growingawareness of the nature and requirements ofprofessionalism and the intrinsic connection of oralhealth and overall health are giving rise to a moresocial conception of dentistry. From this perspectivethe libertarian approach is seen to be inadequatebecause it leaves a segment of the population withlimited or no access to oral health care. Dentists as anorganised profession are beginning to consider thatthey have a responsibility for these individuals inaddition to those who do have access to dental care,namely, their own patients. This responsibility is not

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74theirs alone, however, but requires the support ofpolitical authorities to provide the funding for basicoral health care for those who cannot afford it. Asmentioned above in Chapter Two, individual dentistsshould consider how they can meet the needs of atleast some of these actual or potential patients.However, the professional associations of dentists alsohave a role to play, first by developing policiespromoting universal access to oral health care andsecondly by lobbying forcefully the politicalauthorities to fund such access.

If the libertarian approach to justice cannot meet theneeds of all those in need of dental care, can one ofthe other three approaches serve this purpose? Thosewho have considered this matter have reached noconsensus on which approach is superior. Each oneclearly has very different results when applied to theissues mentioned above, whether at the macro, mesoor micro level. The utilitarian approach can be usefulfor health planners but is probably the most difficultfor individual dentists to practise, since it requires agreat deal of data on the probable outcomes ofdifferent interventions, not just for the dentist’s ownpatients but for all others. The choice between theother two (or three, if the libertarian is included) willdepend on the dentist’s own personal morality as wellas the socio-political environment in which he or shepractises. Some countries, such as the U.S.A., favourthe libertarian approach; others, e.g., Sweden, areknown for their longstanding egalitarianism; whilestill others, such as post-apartheid South Africa, areattempting a restorative approach. Despite theirdifferences, two or more of these concepts of justiceoften coexist in national health systems, and in thesecountries dentists may be able to choose a practice


75setting (e.g., wealthy or poor neighbourhood, urbanor rural community) that accords with their ownpreferred approach.

Public healthThe term ‘public health’, as used here, refers both tothe health of the public and also to the dentalspecialty that deals with oral health from apopulation perspective rather than on an individualbasis. There is a great need for specialists in this fieldin every country to advise on and advocate for publicpolicies that promote good oral health, as well as toengage in activities to protect the public frompreventable diseases and other oral health hazards.The practice of public health (sometimes called‘public health dentistry’ or ‘community dentistry’)relies heavily for its scientific basis on epidemiology,which is the study of the distribution anddeterminants of health and disease in populations. Alldentists need to be aware of the social andenvironmental determinants that influence the healthstatus of their individual patients.

Public health measures such as community waterfluoridation and tobacco-free workplaces areimportant factors in the oral health of individuals butsocial factors such as housing, nutrition andemployment are equally, if not more, significant.Dentists are seldom able to treat the social causes oftheir individual patients’ illnesses, although theyshould be able refer the patients to available socialservices. However, they can contribute, even ifindirectly, to long-term solutions to these problems byparticipating in public health and health educationactivities, monitoring and reporting environmentalhazards, identifying and publicising adverse health

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76effects from social problems such as abuse andviolence, and advocating for improvements in publichealth services.

Sometimes, though, the interests of public healthmay conflict with those of individual patients, forexample, when notification is required for certaincontagious diseases or for cases of child or elderabuse. These are examples of dual-loyalty situationsas described above. Procedures for dealing with theseand related situations are discussed under‘confidentiality’ in Chapter Two of this Manual. Ingeneral, dentists should attempt to find ways tominimise any harm that individual patients mightsuffer as a result of meeting public healthrequirements. For example, when reporting isrequired, the patient’s confidentiality should beprotected to the greatest extent possible whilefulfilling the legal requirements.

A different type of conflict between the interests ofindividual patients and those of society arises whendentists are asked to assist patients to receive benefitsto which they are not entitled, such as insurancepayments. Dentists have been vested with theauthority to certify that patients have the appropriatedental condition that would qualify them for suchbenefits. Although some dentists are unwilling todeny requests from patients for certificates that donot apply in their circumstances, they should ratherhelp their patients find other means of support thatdo not require unethical behaviour.

Global HealthThe recognition that dentists have responsibilities tothe society in which they live can be expanded to


77include a responsibility for global health. This termrefers to health problems, issues and concerns thattranscend national boundaries, that may beinfluenced by circumstances or experiences in othercountries, and that are best addressed by cooperativeactions and solutions at the international level. Globalhealth is part of the much larger movement ofglobalization that encompasses informationexchange, commerce, politics, tourism and manyother human activities.

The basis of globalization is the recognition thatindividuals and societies are increasinglyinterdependent. This is clearly evident with regard tohuman health, as the rapid spread of diseases such asinfluenza and SARS has shown. Such epidemics requireinternational action for their control. The failure torecognise and treat highly contagious diseases in onecountry can have devastating effects on patients inother countries. For this reason, the ethical concerns ofdentists extend far beyond their individual patients andeven their communities and nations.

The development of a global view of health hasresulted in an increasing awareness of healthdisparities throughout the world. Despite large-scalecampaigns to combat premature mortality anddebilitating morbidity in the poorest countries, whichhave resulted in certain success stories such as theelimination of smallpox, the gap in health statusbetween high and low-income countries continues towiden. This is partly due to HIV/AIDS, which has hadits worst effects in poor countries, but it is also due tothe failure of low-income countries to benefit fromthe increase in wealth that the world as a whole hasexperienced during the past decades.

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78Although the causes of poverty are largely politicaland economic and are therefore far beyond thecontrol of dentists and their associations, dentists dohave to deal with the oral health problems that resultfrom poverty. In low-income countries dentists havefew resources to offer these patients and areconstantly faced with the challenge of allocatingthese resources in the fairest way. Even in middle andhigh-income countries, dentists encounter patientswho are directly affected by globalization, such asrefugees, who often do not have access to the dentalcoverage that many citizens of those countries enjoy.In its Nairobi Declaration on Oral Health in Africathe FDI recognises these disparities and encourages allefforts to promote access to oral health care for all.As professionals concerned about their patients,dentists should actively promote interventions,behaviours and policies that help to narrow the oralhealth gap between the rich and poor

Another feature of globalization is the internationalmobility of health professionals, including dentists.The outflow of dentists from developing to highlyindustrialised countries has been advantageous forthe receiving countries but not for the exportingcountries. The FDI, in its Policy Statement onEthical International Recruitment of Oral HealthProfessionals, makes four specific recommendationsto national dental associations for preventing theexploitation of both the developing countries anddentists from those countries:


79• Collaborate with their governments to ensure that

an adequate number of dentists are educated andlicensed to practise, taking into account nationalneeds and resources;

• Promote policies and strategies that enhanceeffective retention of dentists in their countries;

• Promote strategies with partners to lessen theadverse effects of emigration of dentists andminimise their impact on health systems; and

• Encourage their governments to provide oral healthprofessionals legally recruited from abroad whomeet the destination countries’ practicerequirements with employment rights andprotections equivalent to other oral healthprofessionals in their countries, including careerssupport and access to continuing professionaldevelopment.

Dentists have a long tradition of volunteering theirexperience and skills in underserviced areas, both inhumanitarian disasters and emergencies and insituations of chronic need. Volunteer dentists workingin development projects run by non-governmentalorganisations (NGOs) provide improved access to oralhealth care for many communities and can be animportant means of knowledge transfer fromdeveloped to developing countries. However, suchprojects should be properly coordinated andintegrated into the local health care system in orderto address the real needs of the communities. TheFDI’s policy statement, Guidelines for DentalVolunteers, underlines the importance of project

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80planning and integration for sustainable and long-term development in receiving communities.

Back to the Case StudyAccording to the analysis of the dentist-societyrelationship presented in this chapter, Dr. S hascorrectly diagnosed the problem she faces as ethicalin nature, requiring consideration of justice (fairness)in dealing with patients. When one is faced with anethical issue for which the alternatives all have seriousdrawbacks, it is often helpful to explore newapproaches. In this case, Dr. S may try to recruit anadditional dentist to share the patient load. If this isnot possible, she could remind her former colleaguethat at least one dental code of ethics, that of theAmerican Dental Association, states: “Once a dentisthas undertaken a course of treatment, the dentistshould not discontinue that treatment without givingthe patient adequate notice and the opportunity toobtain the services of another dentist. Care should betaken that the patient’s oral health is not jeopardisedin the process.” The colleague may then be willing toretain at least some of his patients. If none of thesestrategies proves successful, Dr. S can consider howthe different approaches to justice mentioned abovewould determine her choice of patients. She can thenimplement a policy that accords most closely with herpreferred approach.


81CHAPTER FOUR – DENTISTS

AND COLLEAGUES

Objectives

After working through this chapter you should be able to:

• describe how dentists should behave towards one another

• justify reporting unethical behaviour of colleagues

• identify the main ethical principles relating tocooperation with others in the care of patients

• explain how to resolve conflicts with otherhealthcare providers

Case Study #3Dr. C, a newly qualified endodontist, has just takenover the practice of the only endodontist in amedium-sized community. The four general practicedentists in the community are relieved that they cancontinue their referrals without interruption. Duringhis first three months in the community, Dr. C isconcerned that a significant number of the patientsreferred by one of the general practice dentists showevidence of substandard treatment. As a newcomer,Dr. C is reluctant to criticise the referring dentistpersonally or to report him to higher authorities.However, she feels that she must do something toimprove the situation.

The need for collaborationAlthough most dentists may think of themselves firstand foremost as private practitioners, they areincreasingly reliant on others to meet the oral health

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82needs of their patients. This chapter will deal withethical issues that arise in the relationships of dentistsboth with their dentist colleagues and with other oralhealth care personnel. Some issues are common toboth; others arise only in one or the otherrelationship. Many of these issues are relatively new,since they result from recent changes in dentistry andhealth care. A brief description of these changes is inorder, since they pose significant challenges to thetraditional practice of dentistry.

With the rapid growth in scientific knowledge and itsclinical applications, dentistry has become increasinglycomplex. Individual dentists cannot possibly beexperts in all their patients’ oral diseases andpotential treatments and they need the assistance ofother specialist dentists and skilled healthprofessionals such as dental hygienists and assistants,laboratory technicians, physicians, pharmacists andspeech therapists. Dentists need to know how toaccess the relevant skills that their patients requireand that they themselves lack. Moreover, it is normalfor dentists in many countries to delegate certainclinical procedures to ancillary dental workers if thosepersons have undergone the necessary training andare legally permitted to practise.

As discussed in Chapter Two, dental paternalism hasbeen gradually eroded by the increasing recognitionof the right of patients to make their own health caredecisions. As a result, a cooperative model ofdecision-making has replaced the authoritarian modelthat was characteristic of traditional dentalpaternalism. The same thing is happening inrelationships between dentists and other healthprofessionals. The latter are increasingly unwilling to


83follow dentists’ orders without knowing the reasonsbehind the orders. They see themselves asprofessionals with specific ethical responsibilitiestowards patients; if their perception of theseresponsibilities conflicts with the dentist’s orders, theyfeel that they must question or even challenge theorders. Whereas under the authoritarian model ofdecision-making there was never any doubt aboutwho was in charge and who should prevail whenconflict occurred, the cooperative model can give riseto disputes about appropriate patient care.Developments such as these are changing the ‘rulesof the game’ for the relationships of dentists withtheir dentist colleagues and other healthprofessionals. The remainder of this chapter willidentify some problematic aspects of theserelationships and suggest ways of dealing with them.

Relationships among Dentist Colleagues,Teachers and StudentsAs members of the dental profession, dentists havetraditionally been expected to treat their colleaguesrespectfully and to work cooperatively to maximisepatient benefit. The FDI International Code ofDental Ethics states that dentists “should refer foradvice and/or treatment any patient requiring a levelof competence beyond that held.” The following tworelationships between dentists have generally beenconsidered unethical: (1) paying or receiving any feeor any other consideration solely to procure thereferral of a patient (‘fee-splitting’); and (2) luringpatients from colleagues. These two practices, alongwith a third obligation, to report unethical orincompetent behaviour by colleagues, are discussedbelow.

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84In the Hippocratic tradition of dental ethics, dentistsowe special respect to their teachers. Althoughpresent-day dental education involves multiplestudent-teacher interactions rather than the one-on-one apprentice relationship that was the norm beforethe 20th century, it is still dependent on the good willand dedication of practising dentists, who oftenreceive no remuneration for their teaching activities.Dental students owe a debt of gratitude to theirteachers, without whom dental education would bereduced to self-instruction.

For their part, teachers have an obligation to treattheir students respectfully and to serve as good rolemodels in dealing with patients. The so-called ‘hiddencurriculum’ of dental education, i.e., the standards ofbehaviour exhibited by practising dentists, is muchmore influential than the explicit curriculum of dentalethics, and if there is a conflict between therequirements of ethics and the attitudes andbehaviour of their teachers, dental students are morelikely to follow their teachers’ example.

Teachers have a particular obligation not toencourage or allow students to engage in unethicalpractices, such as providing treatments that meet thestudents’ educational needs rather than the patients’clinical needs. Given the unequal power balancebetween students and teachers and the consequentreluctance of students to question or refuse suchsuggestions, teachers need to ensure that they arenot pressuring students to act unethically. In manydental schools, there are class representatives ordental student associations that, among their otherroles, may be able to raise concerns about ethicalissues in dental education. Students should have


85access to such mechanisms where they can raiseconcerns without necessarily being identified as thewhistle-blower, as well as access to appropriatesupport if it becomes necessary to take the issue to amore formal process.

For their part, dental students are expected to exhibithigh standards of ethical behaviour as appropriate forfuture dentists. They should treat other students ascolleagues and be prepared to offer help when it isneeded, including corrective advice in regard tounprofessional behaviour. They should also contributefully to shared projects and duties such as studyassignments.

Fee-splitting and AdvertisingSince dentistry is primarily a profession and onlysecondarily a business, not all means of maximisingincome, even if legal, are considered to be ethical. Forexample, fee-splitting, which involves a payment fromone dentist to another simply for referring a patient,is forbidden in codes of ethics such as the AmericanDental Association Principles of Ethics and Code ofProfessional Conduct. The reason for thisprohibition is the danger that dentists will, simply forfinancial gain, refer patients who do not needspecialist treatment.

An apparently more common technique formaximising income, often at the expense of otherdentists, is advertising. Until fairly recently, advertisingwas considered unprofessional – suitable forpromoting sales of consumer products but not ofhealth services. As a result of social and legal changesin some countries, advertising by dentists is no longerforbidden and there is no mention of it in the FDI

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86International Principles of Ethics for the DentalProfession. However, various national dentalassociations place restrictions on advertising by theirmembers. For example, the Canadian DentalAssociation Code of Ethics states, “Dentists shouldbuild their reputation on their professional ability andintegrity. Dentists should participate in healthpromotion programs that are in the best interest ofthe public and supported by the profession. Dentistsshall conduct any promotional activity in accordancewith acceptable professional standards and withinapplicable legislation.”

Besides these legitimate goals, advertising can also beused for unethical purposes, such as luring patientsfrom other dentists and convincing patients to undergotreatment, especially cosmetic procedures, that theydo not need. Not only are these purposes harmful toother dentists and to patients but they reflect poorlyon the dental profession as a whole, contrary to therequirement of the FDI International Principles ofEthics for the Dental Profession that the dentist“should act in a manner which will enhance theprestige and reputation of the profession.”

Reporting unsafe or unethical practicesDentistry has traditionally taken pride in its status as aself-regulating profession. In return for the privilegesaccorded to it by society and the trust given to itsmembers by their patients, the dental profession hasestablished high standards of behaviour for itsmembers and disciplinary procedures to investigateaccusations of misbehaviour and, if necessary, topunish the wrongdoers. This system of self-regulationhas sometimes failed, and in recent years steps havebeen taken to make the profession more


87accountable, for example, by appointing lay membersto regulatory authorities. The main requirement forself-regulation, however, is wholehearted support bydentists for its principles and their willingness torecognise and deal with unsafe and unethicalpractices. The increasing use of constructive andmutually supportive peer review groups, wheredentists discuss and review their successes anddifficulties with local colleagues, is a welcomedevelopment, especially in general dental practicewhere, unlike in hospitals or health clinics, dentistsmay lack the benefit of working in an environmentthat naturally fosters peer review.

The obligation to report incompetence, misconduct orimpairment on the part of one’s colleagues isemphasised in codes of dental ethics. For example,the American Dental Association Principles of Ethicsand Code of Professional Conduct states that“Dentists shall be obliged to report to the appropriatereviewing agency…instances of gross or continualfaulty treatment by other dentists” and “All dentistshave an ethical obligation to urge chemically impairedcolleagues to seek treatment. Dentists with first-handknowledge that a colleague is practicing dentistrywhen so impaired have an ethical responsibility toreport such evidence to the professional assistancecommittee of a dental society.” The application ofthis principle is seldom easy, however. On the onehand, a dentist may be tempted to attack thereputation of a colleague for unworthy personalmotives, such as jealousy, or in retaliation for aperceived insult by the colleague. A dentist may alsobe reluctant to report a colleague’s misbehaviourbecause of friendship or sympathy (“there but for thegrace of God go I”). The consequences of such

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88reporting can be very detrimental to the one whoreports, including almost certain hostility on the partof the accused and possibly other colleagues as well.

Despite these drawbacks to reporting wrongdoing, itis a professional duty of dentists. Not only are theyresponsible for maintaining the good reputation ofthe profession, but they are often the only ones whorecognise incompetence, impairment or misconduct.However, reporting colleagues to the disciplinaryauthority should normally be a last resort after otheralternatives have been tried and found wanting. Thefirst step might be to approach the colleague and saythat you consider his or her behaviour unsafe orunethical. If the matter can be resolved at that level,there may be no need to go further. If not, then itmay be necessary to take the next step of informingthe disciplinary authority.

Relationships with Other Health ProfessionalsChapter Two on relationships with patients beganwith a discussion of the great importance of respectand equal treatment in the dentist-patientrelationship. The principles set forth in that discussionare equally relevant for relationships with co-workers.In particular, the prohibition against discrimination ongrounds such as race, creed, colour, sex or nationalorigin (American Dental Association Principles ofEthics and Code of Professional Conduct) isapplicable in dealings with all those with whomdentists interact in caring for patients and otherprofessional activities.

Non-discrimination is a passive characteristic of arelationship. Respect is something more active andpositive. With regard to other healthcare providers,


89such as dental hygienists and assistants, laboratorytechnicians, etc., it entails an appreciation of theirskills and experience insofar as these can contributeto the care of patients. The FDI International Codeof Dental Ethics states that dentists “should behavetowards all members of the oral health team in aprofessional manner and should be willing to assistcolleagues professionally and maintain respect fordivergence of professional opinion.” All healthcareproviders are not equal in terms of their educationand training, but they do share a basic humanequality as well as similar concern for the well-beingof patients.

As with patients, though, there are legitimategrounds for refusing to enter or for terminating arelationship with another health care provider. Theseinclude lack of confidence in the ability or integrity ofthe other person and serious personality clashes.Distinguishing these from less worthy motives canrequire considerable ethical sensitivity on the dentist’s part.

CooperationDentistry is at the same time a highly individualisticand a highly cooperative profession. On the onehand, dentists are quite possessive of ‘their’ patients.It is claimed, with good reason, that the individualdentist-patient relationship is the best means ofattaining the knowledge of the patient and continuityof care that are optimal for the prevention andtreatment of oral disease. The retention of patientsalso benefits the dentist, not least financially. At thesame time, as described above, dentistry is highlycomplex and specialised, thus requiring closecooperation among practitioners with different but

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90complementary knowledge and skills. This tensionbetween individualism and cooperation has been arecurrent theme in dental ethics.

The weakening of dental paternalism has beenaccompanied by the disappearance of the belief thatdentists ‘own’ their patients. The traditional right ofpatients to ask for a second opinion has beenexpanded to include access to other healthcareproviders who may be better able to meet theirneeds. Dentists should facilitate the exercise of thisright although, as noted above, they are not to profitfrom relationships with other dentists by fee-splitting.

Whereas relationships among dentists are governedby generally well-formulated and understood rules,relationships between dentists and other healthcareprofessionals are in a state of flux and there is somedisagreement about what their respective roles shouldbe. As noted above, many other health professionalsfavour a team approach to patient care in which theviews of all caregivers are given equal consideration,and they consider themselves accountable to thepatient, not to the dentist. Many dentists, on theother hand, feel that even if the team approach isadopted, there has to be one person in charge, anddentists are best suited for that role given theireducation and experience. This view is supported bythe FDI International Principles of Ethics for theDental Profession where it states, “The dentist mustaccept full responsibility for all treatmentundertaken…” and the FDI Statement onSupervision of Auxiliaries within the DentalTeam: “the dentist is also responsible for the support,guidance and supervision of auxiliaries within thedental team.”


91Although some dentists may resist challenges to theirtraditional, almost absolute, authority, it seems certainthat their role will change in response to claims byboth patients and other healthcare providers forgreater participation in dental decision-making.Dentists will have to be able to justify theirrecommendations to others and persuade them toaccept these recommendations. In addition to thesecommunication skills, dentists will need to be able toresolve conflicts that arise among the differentparticipants in the care of the patient.

Conflict resolutionAlthough dentists can experience many differenttypes of conflicts with other dentists and healthcareproviders, for example, over office procedures orremuneration, the focus here will be on conflictsabout patient care. Ideally, oral health care decisionswill reflect agreement among the patient, dentistsand all others involved in the patient’s care. However,uncertainty and diverse viewpoints can give rise todisagreement about the goals of care or the meansof achieving those goals. Limited healthcareresources and organisational policies may also makeit difficult to achieve consensus. Dentists areparticularly susceptible to such conflicts because ofthe lack of generally accepted standards of care andbecause so many patients cannot afford high qualityoral health care.

Disagreements among dentists and/or dentalauxiliaries about the goals of care and treatment orthe means of achieving those goals should beclarified and resolved by the individuals involved so asnot to compromise their relationships with the

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92patient. The following guidelines can be useful forresolving such conflicts:

• Conflicts should be resolved as informally aspossible, for example, through direct negotiationbetween the persons who disagree, moving to moreformal procedures only when informal measureshave been unsuccessful.

• The opinions of all those directly involved should beelicited and given respectful consideration.

• The informed choice of the patient, or authorised substitute decision-maker, regardingtreatment should be the primary consideration in resolving disputes.

• If the dispute is about which options the patientshould be offered, a broader rather than a narrowerrange of options is usually preferable. If a preferredtreatment is not available because of resourcelimitations, the patient should normally be informed of this.

• If, after reasonable effort, agreement orcompromise cannot be reached through dialogue,the decision of the person with the right orresponsibility for making the decision should beaccepted. If it is unclear or disputed who has theright or responsibility to make the decision,mediation, arbitration or adjudication should besought.

If health care providers cannot support the decisionthat prevails as a matter of professional judgement orpersonal morality, they should be allowed to


93withdraw from participation in carrying out thedecision, after ensuring that the person receiving careis not at risk of harm or abandonment.

Back to the Case StudyDr. C is right to be alarmed by the treatment resultsof the referring dentist. She has an ethical duty not toignore this problem but to do something about it. Asa first step, she might try to have a discussion withthe referring dentist to communicate her concernsand see whether he might voluntarily take correctivemeasures. If this does not succeed, she could raisethe issue with the other dentists in the community tosee whether they share her misgivings and seek theiradvice on further action. Together they may be ableto convince the problem dentist to address the issue.If none of these initiatives has the desired effect, Dr Ccan approach the appropriate dentist licensing bodyand ask it to investigate. Dr. C also has to decidewhether she should inform the patients about theirsubstandard treatment. On this issue the AmericanDental Association’s Principles of Ethics and Codeof Professional Conduct advises that “Patientsshould be informed of their present oral health statuswithout disparaging statements about prior services.”

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94CHAPTER FIVE – ETHICS AND

DENTAL RESEARCH

Objectives

After working through this chapter you should be able to:

• identify the main principles of research ethics

• know how to balance research and clinical care

• satisfy the requirements of ethics review committees

Case Study #4Dr. R, a general practice dentist in a small rural town,is approached by a contract research organisation(C.R.O.) to participate in a clinical trial of a newsealant. He is offered a sum of money for eachpatient that he enrols in the trial. The C.R.O.representative assures him that the trial has receivedall the necessary approvals, including one from anethics review committee. Dr. R has never participatedin a trial before and is pleased to have thisopportunity, especially with the extra money. Heaccepts without inquiring further about the scientificor ethical aspects of the trial.

Importance of Dental ResearchDentistry is not an exact science in the way thatmathematics and physics are. It is evidence based andhas many general principles that are valid most of thetime, but every patient is different and what is aneffective treatment for 90% of the population maynot work for the other 10%. Thus, dentistry isinherently experimental. Even the most widely


95accepted treatments need to be monitored andevaluated to determine whether they are effective forspecific patients and, for that matter, for patients ingeneral. This is one of the functions of dentalresearch.

Another, perhaps better known, function is thedevelopment of new dental materials, devices andtechniques. Great progress has been made in thisarea over the past 50 years and today there is moredental research underway than ever before.Nevertheless, there are still many unansweredquestions about the causes of oral diseases (bothfamiliar and novel ones) and the best ways to preventor cure them. Dental research is the only means ofanswering these questions.

Research in Dental PracticeAll dentists make use of the results of dental researchin their clinical practice. To maintain theircompetence, dentists must keep up with the currentresearch in their area of practice through ContinuingDental Education/Continuing ProfessionalDevelopment programs, dentistry journals andinteraction with knowledgeable colleagues. Even ifthey do not engage in research themselves, dentistsmust know how to interpret the results of researchand apply them to their patients. Thus, a basicfamiliarity with research methods is essential forcompetent dental practice. The best way to gain thisfamiliarity is to take part in a research project, eitheras a dental student or following qualification.

Ideally, all aspects of dental practice should bevalidated by research. Materials such as dentalamalgams and pharmaceutical products such as

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96anaesthetics do require evidence for their safety andefficacy before they are given governmental approvalfor their distribution and use. However, dentaltechniques do not require any such approval. Mostdentists trust that the techniques they learn in dentalschool are appropriate but are ready to adopt newones if these appear to be better. Rather than relyingon their own, necessarily limited, experience, dentistsneed to have recourse to the results of research fordetermining which materials, drugs and techniquesare best for their patients.

The most common method of research for comparingand evaluating drugs is the clinical trial process,which with certain modifications serves for materialsand techniques as well. The process usually beginswith laboratory studies followed by testing onanimals. If these prove promising, the four steps, orphases, of clinical research, are next:

• Phase one research, usually conducted on arelatively small number of healthy volunteers, whoare often paid for their participation, is intended todetermine what dosage of a drug is required toproduce a response in the human body, how thebody processes the drug, and whether the drugproduces toxic or harmful effects.

• Phase two research is conducted on a group ofpatients who have the disease that the drug isintended to treat. Its goals are to determinewhether the drug has any beneficial effect on thedisease and has any harmful side effects.


97• Phase three research is the clinical trial, in which the

drug is administered to a large number of patientsand compared to another drug, if there is one forthe condition in question, and/or to a placebo.Where possible, such trials are ‘double-blinded’, i.e.,neither research subjects nor their dentists knowwho is receiving which drug or placebo.

• Phase four research takes place after the drug islicensed and marketed. For the first few years, anew drug is monitored for side effects that did notshow up in the earlier phases. Additionally thepharmaceutical company is usually interested inhow well the drug is being received by physiciansand dentists who prescribe it and patients who take it.

The rapid increase in recent years in the number ofongoing trials has required finding and enrolling ever-larger numbers of patients to meet the statisticalrequirements of the trials. For dental research, thosein charge of the trials, whether academic researchers or industry, now rely on many dentists,often in different countries, to enrol patients asresearch subjects.

Although such participation in research is valuableexperience for dentists, there are potential problemsthat must be recognised and avoided. In the firstplace, the dentist’s role in the dentist-patientrelationship is different from the researcher’s role inthe researcher-research subject relationship, even ifthe dentist and the researcher are the same person.The dentist’s primary responsibility is the health andwell-being of the patient, whereas the researcher’sprimary responsibility is the generation of knowledge,

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98which may or may not contribute to the researchsubject’s health and well-being. Thus, there is apotential for conflict between the two roles. Whenthis occurs, the dentist role must take precedenceover the researcher. What this means in practice willbe evident below.

Another potential problem in combining these tworoles is conflict of interest. Dental research is a well-funded enterprise, and dentists are sometimes offeredconsiderable rewards for participating. These caninclude cash payments for enrolling research subjects,equipment such as computers to transmit theresearch data, invitations to conferences to discussthe research findings, and co-authorship ofpublications on the results of the research. Thedentist’s interest in obtaining these benefits cansometimes conflict with the duty to provide thepatient with the best available treatment. It can alsoconflict with the right of the patient to receive all thenecessary information to make a fully informeddecision whether or not to participate in a researchstudy.

These potential problems can be overcome. Theethical values of the dentist – compassion,competence, autonomy – apply to the dentalresearcher as well. As long as dentists understand andfollow the basic rules of research ethics, they cansuccessfully integrate research into their clinicalpractice.

Ethical RequirementsThe basic principles of research ethics are wellestablished. It was not always so, however. Manyprominent medical researchers in the 19th and 20th


99centuries conducted experiments on patients withouttheir consent and with little if any concern for thepatients’ well-being. Although there were somestatements of research ethics dating from the early20th century, these did not prevent healthcareprofessionals in many different countries – and intimes of peace and war alike – from performingresearch on subjects that clearly violated fundamentalhuman rights. Following World War Two, someGerman physicians were tried and convicted by aspecial tribunal at Nuremberg, Germany. The basis ofthe judgment is known as the Nuremberg Code,which has served as one of the foundationaldocuments of modern research ethics. Among the tenprinciples of this Code is the requirement of voluntaryconsent if a patient is to serve as a research subject.

The World Medical Association was established in1947, the same year that the Nuremberg Code wasset forth. Conscious of the violations of medicalethics before and during World War Two, thefounders of the WMA immediately took steps toensure that physicians would at least be aware oftheir ethical obligations. In 1954, after several yearsof study, the WMA adopted a set of Principles forThose in Research and Experimentation. Thisdocument was revised over the next ten years andeventually was adopted as the Declaration ofHelsinki (DoH) in 1964. It was further revised in1975, 1983, 1989, 1996 and 2000. The DoH is aconcise summary of research ethics. Other, muchmore detailed, documents have been produced inrecent years on research ethics in general (e.g.,Council for International organisations of MedicalSciences, International Ethical Guidelines forBiomedical Research Involving Human Subjects,

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1001993, revised in 2002) and on specific topics inresearch ethics (e.g., Nuffield Council on Bioethics[UK], The Ethics of Research Related toHealthcare in Developing Countries, 2002).

Despite the different scope, length and authorship ofthese documents, they agree to a very large extent onthe basic principles of research ethics. These principleshave been incorporated in the laws and/or regulationsof many countries and international organisations,including those that deal with the approval of drugsand medical devices. Here is a brief description of theprinciples, taken primarily from the DoH.Unfortunately, there is no comparable statement ofresearch ethics for dentists. The 2000 SummaryCode of Ethics of the International and AmericanAssociations for Dental Research(www.dentalresearch.org/about/aadr/ethics.html)provides little if any specific guidance for howresearchers should deal with ethical issues.

Ethics Review Committee ApprovalParagraphs 13 and 14 of the DoH stipulate that everyproposal for research on human subjects must bereviewed and approved by an independent ethicscommittee before it can proceed. In order to obtainapproval, researchers must explain the purpose andmethodology of the project; demonstrate howresearch subjects will be recruited, how their consentwill be obtained and how their privacy will beprotected; specify how the project is being funded;and disclose any potential conflicts of interest on thepart of the researchers. The ethics committee mayapprove the project as presented, require changesbefore it can start, or refuse approval altogether.Many committees have a further role of monitoring


101projects that are underway to ensure that theresearchers fulfil their obligations and they can ifnecessary stop a project because of seriousunexpected adverse events.

The reason why ethics committee approval of aproject is required is that neither researchers norresearch subjects are always knowledgeable andobjective enough to determine whether a project isscientifically and ethically appropriate. Researchersneed to demonstrate to an impartial expertcommittee that the project is worthwhile, that theyare competent to conduct it, and that potentialresearch subjects will be protected against harm tothe greatest extent possible.

One unresolved issue regarding ethics committeereview is whether a multi-centre project requirescommittee approval at each centre or whetherapproval by one committee is sufficient. If the centresare in different countries, review and approval isgenerally required in each country.

Scientific MeritParagraph 11 of the DoH requires that researchinvolving human subjects must be justifiable onscientific grounds. This requirement is meant toeliminate projects that are unlikely to succeed, forexample, because they are methodologicallyinadequate, or that, even if successful, will likelyproduce trivial results. If patients are being asked toparticipate in a research project, even where risk ofharm is minimal, there should be an expectation thatimportant scientific knowledge will be the result. To ensure scientific merit, paragraph 11 requires thatthe project be based on a thorough knowledge of the

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102literature on the topic and on previous laboratory and,where appropriate, animal research that gives goodreason to expect that the proposed intervention will beefficacious in human beings. All research on animalsmust conform to ethical guidelines that minimise thenumber of animals used and prevent unnecessarypain. Paragraph 15 adds a further requirement – thatonly scientifically qualified persons should conductresearch on human subjects. The ethics reviewcommittee needs to be convinced that theseconditions are fulfilled before it approves the project.

Social ValueOne of the more controversial requirements of aresearch project is that it contribute to the well-beingof society in general. It used to be widely agreed thatadvances in scientific knowledge were valuable inthemselves and needed no further justification.However, as resources available for health researchare increasingly inadequate, social value has emergedas an important criterion for judging whether aproject should be funded.

Paragraphs 18 and 19 of the DoH clearly favour theconsideration of social value in the evaluation ofresearch projects. The importance of the project’sobjective, understood as both scientific and socialimportance, should outweigh the risks and burdensto research subjects. Furthermore, the populations inwhich the research is carried out should benefit fromthe results of the research. This is especially importantin countries where there is potential for unfairtreatment of research subjects who undergo the risksand discomfort of research while the drugs developedas a result of the research only benefit patientselsewhere.


103The social worth of a research project is more difficultto determine than its scientific merit but that is not agood reason for ignoring it. Researchers, and ethicsreview committees, must ensure that patients are notsubjected to tests that are unlikely to serve any usefulsocial purpose. To do otherwise would waste valuablehealth resources and weaken the reputation ofresearch as a major contributing factor to humanhealth and well-being.

Risks and BenefitsOnce the scientific merit and social worth of theproject have been established, it is necessary for theresearcher to demonstrate that the risks to theresearch subjects are not unreasonable ordisproportionate to the expected benefits of theresearch, which may not even go to the researchsubjects. A risk is the potential for an adverseoutcome (harm) to occur. It has two components: (1)the likelihood of the occurrence of harm (from highlyunlikely to very likely), and (2) the severity of theharm (from trivial to permanent severe disability ordeath). A highly unlikely risk of a trivial harm wouldnot be problematic for a good research project. Atthe other end of the spectrum, a likely risk of aserious harm would be unacceptable unless theproject provided the only hope of treatment forterminally ill research subjects. In between these twoextremes, paragraph 17 of the DoH requiresresearchers to adequately assess the risks and be surethat they can be managed. If the risk is entirelyunknown, then the researcher should not proceedwith the project until some reliable data are available,for example, from laboratory studies or experimentson animals.

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104Informed Consent

The first principle of the Nuremberg Code reads asfollows: “The voluntary consent of the human subject is absolutely essential.” The explanatoryparagraph attached to this principle requires, amongother things, that the research subject “should have sufficient knowledge and comprehension of the elements of the subject matter involved as toenable him to make an understanding andenlightened decision.”

The DoH goes into some detail about informedconsent. Paragraph 22 specifies what the researchsubject needs to know in order to make an informeddecision about participation. Paragraph 23 warnsagainst pressuring individuals to participate inresearch, since in such circumstances the consent maynot be entirely voluntary. Paragraphs 24 to 26 dealwith research subjects who are unable to giveconsent (minor children, severely mentallyhandicapped individuals, unconscious patients). Theycan still serve as research subjects but only underrestricted conditions.

The DoH, like other research ethics documents,recommends that informed consent be demonstratedby having the research subject sign a ‘consent form’(paragraph 22). Many ethics review committeesrequire the researcher to provide them with theconsent form they intend to use for their project. Insome countries these forms have become so long anddetailed that they no longer serve the purpose ofinforming the research subject about the project. Inany case, the process of obtaining informed consentdoes not begin and end with the form being signedbut must involve a careful oral explanation of the


105project and all that participation in it will mean to theresearch subject. Moreover, research subjects shouldbe informed that they are free to withdraw theirconsent to participate at any time, even after theproject has begun, without any sort of reprisal fromthe researchers or other dentists and without anycompromise of their health care.

ConfidentialityAs with patients in clinical care, research subjectshave a right to privacy with regard to their personalhealth information. Unlike clinical care, however,research requires the disclosure of personal healthinformation to others, including the wider scientificcommunity and sometimes the general public. Inorder to protect privacy, researchers must ensure thatthey obtain the informed consent of research subjectsto use their personal health information for researchpurposes, which requires that the subjects are told inadvance about the uses to which their information isgoing to be put. As a general rule, the informationshould be de-identified and should be stored andtransmitted securely.

Conflict of RolesIt was noted earlier in this chapter that the dentist’srole in the dentist-patient relationship is differentfrom the researcher’s role in the researcher-researchsubject relationship, even if the dentist and theresearcher are the same person. Paragraph 28 of theDoH requires that in such cases, the dentist role musttake precedence. This means, among other things,that the dentist must be prepared to recommend thatthe patient not take part in a research project if thepatient seems to be doing well with the currenttreatment and the project requires that patients be

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106randomised to different treatments and/or to aplacebo. Only if the dentist, on solid scientificgrounds, is truly uncertain whether the patient’scurrent treatment is as suitable as a proposed newtreatment, or even a placebo, should the dentist askthe patient to take part in the research project.

Honest Reporting of ResultsIt should not be necessary to require that researchresults be reported accurately, but unfortunately therehave been numerous recent accounts of dishonestpractices in the publication of research results.Problems include plagiarism, data fabrication,duplicate publication and ‘gift’ authorship. Suchpractices may benefit the researcher, at least untilthey are discovered, but they can cause great harm topatients, who may be given incorrect treatmentsbased on inaccurate or false research reports, and toother researchers, who may waste much time andresources trying to follow up the studies.

Whistle-blowingIn order to prevent unethical research from occurring,or to expose it after the fact, anyone who hasknowledge of such behaviour has an obligation todisclose this information to the appropriateauthorities. Unfortunately, such whistle-blowing is notalways appreciated or even acted on, and whistle-blowers are sometimes punished or avoided for tryingto expose wrong-doing. This attitude seems to bechanging, however, as both scientists and governmentregulators are seeing the need to detect and punishunethical research and are beginning to appreciate therole of whistle-blowers in achieving this goal.


107Junior members of a research team, such as dentalstudents, may find it especially difficult to act onsuspicions of unethical research, since they may feelunqualified to judge the actions of senior researchersand will likely be subject to punishment if they speakout. At the very least, however, they should refuse toparticipate in practices that they consider clearlyunethical, for example, lying to research subjects orfabricating data. If they observe others engaging insuch practices, they should take whatever steps theycan to alert relevant authorities, either directly oranonymously.

Unresolved IssuesNot all aspects of research ethics enjoy generalagreement. As the biomedical sciences continue toadvance, in areas such as genetics, the neurosciencesand tissue transplantation, new questions ariseregarding the ethical acceptability of techniques,procedures and treatments for which there are noready-made answers. Moreover, some older issues arestill subjects of continuing ethical controversy, forexample, under what conditions should a placeboarm be included in a clinical trial and what continuingcare should be provided to participants in dentalresearch. At a global level, the 10/90 gap in healthresearch (only 10% of global research funding isspent on health problems that affect 90% of theworld’s population) is clearly an unresolved ethicalissue. Furthermore when researchers do addressissues in resource-poor areas of the world, they oftenencounter problems due to conflicts between theirethical outlook and that of the communities wherethey are working. All these topics will require muchfurther analysis and discussion before generalagreement is achieved.

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108Despite all these potential problems, dental researchis a valuable and rewarding activity for dentists anddental students as well as for the research subjectsthemselves. Indeed, dentists and dental studentsshould consider serving as research subjects so thatthey can appreciate the other side of the researcher-research subject relationship.

Back to the Case StudyDr. R should not have accepted so quickly. He shouldfirst find out more about the project and ensure thatit meets all the requirements for ethical research. Inparticular, he should ask to see the protocol that wassubmitted to the ethics review committee and anycomments or conditions that the committee put onthe project. He should only participate in projects inhis area of practice, and he should satisfy himselfabout the scientific merit and social value of theproject. If he is not confident in his ability to evaluatethe project, he should seek the advice of colleaguesin larger centres. He should ensure that he acts in thebest interests of his patients and only enrols thosewho will not be harmed by changing their currenttreatment to the experimental one or to a placebo.He must be able to explain the alternatives to hispatients so they can give fully informed consent toparticipate or not to participate. He should not agreeto enrol a fixed number of patients as subjects sincethis could lead him to pressure patients to agree,perhaps against their best interests. He shouldcarefully monitor the patients in the study forunexpected adverse events and be prepared to adoptrapid corrective action. Finally, he shouldcommunicate to his patients the results of theresearch as they become available.


109CHAPTER SIX – CONCLUSION

Rights and Privileges of DentistsThis Manual has focused on the duties andresponsibilities of dentists, and indeed that is themain substance of dental ethics. However, like allhuman beings, dentists have rights as well asresponsibilities, and dental ethics would beincomplete if it did not consider how dentists shouldbe treated by others, whether patients, society orcolleagues. Indeed, there may be difficulty inmaintaining professional and ethical standards whendentists’ rights are significantly at risk. Thisperspective on dental ethics has become increasinglyimportant as dentists in many countries areexperiencing great frustration in practising theirprofession, whether because of limited resources,government and/or corporate micro-management ofhealth care delivery, sensationalist media reports ofdental errors and unethical dentist conduct, orchallenges to their authority and skills by patients andother health care providers.

Dental associations have an important role to play indefending the rights of dentists, given the threats andchallenges listed above. However, dentists sometimesneed also to be reminded of the privileges they enjoy.Public surveys in many countries have consistentlyshown that dentists are among the most highlyregarded and trusted occupational groups. Theygenerally receive higher than average remuneration(much higher in some countries). They still have agreat deal of clinical autonomy, although not as muchas previously. Some are engaged in an exciting searchfor new knowledge through participation in research.Most important, they provide services that are of

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110great value to individual patients, particularly thosewho are vulnerable and most in need, and to societyin general. Few occupations have the potential to bemore satisfying than dentistry, considering thebenefits that dentists provide — relief of pain andsuffering and cure of illnesses. Fulfilment of theirethical duties may be a small price to pay for all theseprivileges.

Responsibilities to OneselfThis Manual has classified dentists’ ethicalresponsibilities according to their main beneficiaries:patients, society, and colleagues (including otherhealth professionals). Dentists often forget that theyhave responsibilities to themselves, and to theirfamilies, as well. In many parts of the world, being adentist has required devoting oneself to the practiceof dentistry with little consideration for one’s ownhealth and well-being. Working weeks of 60-80hours are not uncommon and vacations areconsidered to be unnecessary luxuries. Althoughmany dentists seem to do well in these conditions,their families may be adversely affected. Otherdentists clearly suffer from this pace of professionalactivity, with results ranging from chronic fatigue tosubstance abuse to suicide. Impaired dentists are adanger to their patients, with fatigue being animportant factor in dental mishaps.

The need to ensure patient safety, as well as topromote a healthy lifestyle for dentists, is beingaddressed in some countries. For example, somedental educational institutions now make it easier forfemale students to interrupt their trainingprogrammes for family reasons. Although measuressuch as these can contribute to dentist health and


111well-being, the primary responsibility for self-carerests with the individual dentist. Besides avoiding suchobvious health hazards as smoking, substance abuseand overwork, dentists should protect and enhancetheir own health and well-being by identifying stressfactors in their professional and personal lives and bydeveloping and practising appropriate copingstrategies. When these fail, they should seek helpfrom colleagues and appropriately qualifiedprofessionals for personal problems that mightadversely affect their relationships with patients,society or colleagues.

The Future of Dental EthicsThis Manual has focussed on the current state ofdental ethics, although with numerous references toits past. However, the present is constantly slippingaway and it is necessary to anticipate the future if weare not to be always behind the times. The future ofdental ethics will depend in large part on the futureof dentistry. In the first decade of the 21st century,dentistry is evolving at a very rapid pace and it isdifficult to predict how it will be practised by the timetoday’s first-year dental students complete theirtraining, and impossible to know what furtherchanges will take place before they are ready toretire. The future will not necessarily be better thanthe present, given widespread political and economicinstability, environmental degradation, the continuingspread of HIV/AIDS and other potential epidemics.Although we can hope that the benefits of dentalprogress will eventually spread to all countries andthat the ethical problems they will face will be similarto those currently being discussed in the wealthycountries, the reverse could happen — countries thatare wealthy now could deteriorate to the point where

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112their dentists have to deal with ever larger numbersof patients who cannot afford oral health care andsevere shortages of dental supplies.

Given the inherent unpredictability of the future,dental ethics needs to be flexible and open to changeand adjustment, as indeed it has been for some timenow. However, we can hope that its basic principleswill remain in place, especially the values ofcompassion, competence and autonomy, along withits concern for fundamental human rights and itsdevotion to professionalism. Whatever changes indentistry occur as a result of scientific developmentsand social, political and economic factors, there willalways be people needing cure if possible and carealways. Dentists have traditionally provided theseservices along with others such as oral healthpromotion and disease prevention. Although thebalance among these activities may change in thefuture, dentists will likely continue to play animportant role in all of them. Since each activityinvolves many ethical challenges, dentists will need tokeep informed about developments in dental ethicsjust as they do in other aspects of dentistry.

This is the end of the Manual but for the reader itshould be just one step in a life-long immersion indental ethics. To repeat what was stated in theIntroduction, this Manual provides only a basicintroduction to dental ethics and some of its centralissues. It is intended to give you an appreciation ofthe need for continual reflection on the ethicaldimension of dentistry, and especially on how to dealwith the ethical issues that you will encounter in yourown practice. The list of resources provided in


113Appendix B can help you deepen your knowledge ofthis field.

APPENDIX A - GLOSSARY

Accountable – answerable to someone for something(e.g., employees are accountable to their employersfor the work they do). Accountability requires beingprepared to provide an explanation for somethingone has done or has not done.

Advocate – (verb) to speak out or take action onbehalf of another person or group; (noun) someonewho acts in this way. Dentists serve as advocates fortheir patients when they call on governments orhealth insurance officials to provide services that theirpatients need but cannot easily obtain on their own.

Beneficence – literally, ‘doing good’. Dentists areexpected to act in the best interests of their patients.

Bioethics –the study of moral issues that occur indentistry, health care and the biological sciences. Ithas four major subdivisions: clinical ethics, whichdeals with issues in patient care (cf. Chapter Two ofthis Manual); research ethics, which deals with theprotection of human subjects in health care research(cf. Chapter Five of this Manual); professionalethics, which deals with the specific duties andresponsibilities that are required of dentists and otherhealth care professions (dental ethics is one type ofprofessional ethics); and public policy ethics, whichdeals with the formulation and interpretation of lawsand regulations on bioethical issues.

Consensus – general, but not necessarily unanimous,agreement.

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114Justice – fair treatment of individuals and groups. AsChapter Three points out, there are differentunderstandings of what constitutes fair treatment inhealth care.

Managed health care – an organisational approach tohealth care in which governments, corporations orinsurance companies decide what services will beprovided, who will provide them (dentists, physicians,other health professionals, etc.), where they will beprovided (clinics, hospitals, the patient’s home, etc.),and other related matters.

Non-maleficence – literally, not doing wrong. Dentistsand dental researchers are to avoid inflicting harm onpatients and research subjects.

Plagiarism – a form of dishonest behaviour whereby aperson copies the work of someone else, forexample, all or part of a published article, andsubmits it as if it were the person’s own work (i.e.,without indicating its source).

Pluralistic – having several or many differentapproaches or features: the opposite of singular oruniform.

Profession – from the word ‘profess’ – to state abelief or a promise in public – which is also the basisof the terms ‘professional’ and ‘professionalism’.

Rational – based on the human capacity forreasoning, i.e., to be able to consider the argumentsfor and against a particular action and to make adecision as to which alternative is better.


115Value – (verb) to consider something to be veryimportant; (noun) something that is considered to bevery important.

Virtue – a good quality in people, especially in theircharacter and behaviour. Some virtues are particularlyimportant for certain groups of people, for example,compassion for dentists, courage for fire-fighters,truthfulness for witnesses, etc.

Whistle-blower – someone who informs people inauthority or the public that an individual or anorganisation is doing something unethical or illegal.(The expression comes from the world of sport,where a referee or umpire blows a whistle to signalan infraction of the rules.)

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116APPENDIX B – DENTAL ETHICS RESOURCES

ON THE INTERNET

General

FDI World Dental Federation:

• International principles of ethics for the dentalprofession (1997) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Ethics/Principles_of_Ethics.pdf

• Guidelines for a code of ethics for dentalpublications (1998) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Ethics/Code_Ethics_Publications.pdf

• Relationship between the dental profession andthird party carriers (1998) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Ethics/Third_Party-Carriers.pdf

• Human Immunodeficiency Virus infection and otherblood borne infections (2000) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Ethics/HIV_Infection.pdf

• Supervision of auxiliaries within the dental team (2000) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Supervision/Super_Auxiliary.pdf

• Oral and dental care of peoplewith disabilities (2003) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Disability/Dental_Care_Disability.pdf


117• Infection control in dentistry (2003) –

www.fdiworldental.org/federation/assets/statements/ENGLISH/Ethics/Infection_control.pdf

• Continuing dental education (2004) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Dental_Education/Continuing_Dental_Education.pdf

• Code of practice on tobacco control for oral healthorganisations (2004) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Ethics/Code_of_practice.pdf

• Guidelines for dental volunteers (2005) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Ethics/Guidelines_dental_volunteers.pdf

• Nairobi Declaration on Oral Health In Africa (2004) –www.fdiworldental.org/public_health/assets/Activities/Nairobi/NairobiDeclarationEng.pdf"

• Improving Access to Oral Care (2005) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Access_to_oral_Health_Care/Improving_access.pdf

• Need and Demand for Oral Health Care (2005) –www.fdiworldental.org/federation/assets/statements/ENGLISH/Demand_for_Care/Demand_for_oral_care.pdf

• Ethical International Recruitment of Oral HealthProfessionals –www.fdiworldental.org/federation/assets/statements/ENGLISH/Ethics/Ethical_Recruitment.pdf

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118International Dental Ethics and Law Society –www.ideals.ac/ (resources - www.ideals.ac/links.php)

International Medical and Dental Ethics Commission –www.imdec.org/

E-course - Ethics and Law: International Principles ofEthics for the Dental Profession –www.dentistry.bham.ac.uk/ecourse/ethics/p-ethicsfordentists.asp

American College of Dentists: Ethics Handbook for Dentists –www.facd.org/acdethics.htm#EthicsHandbook (2004)

American College of Dentists online ethics courses –www.dentalethics.org/

American Society for Dental Ethics (formerly PEDNET) –http://societyfordentalethics.org/

PEDNET - The Professional Ethics in DentistryNetwork (now ASDE) –www.luc.edu/ethics/032310pednet_main.shtml

Consent and Confidentiality

General Dental Council (U.K.): Patient Consent –www.gdc-uk.org/News+publications+and+events/Publications/Guidance+documents/Patient+consent.htm

General Dental Council (U.K.): Principles of PatientConfidentiality – www.gdc-uk.org/News+publications+and+events/Publications/Guidance+documents/Patient+confidentiality.htm


119HIV/AIDS

Resources – www.wits.ac.za/bioethics/

UNAIDS –www.unaids.org/en/in+focus/hiv_aids_human_rights/unaids+activities+hr.asp

Relations with commercial enterprises

Educational resources – www.ama-assn.org/ama/pub/category/5689.html

Resources – www.nofreelunch.org/

Research on human subjects

International Association for Dental Research &American Association for Dental Research:IADR/AADR Code of Ethics –www.iadr.org/about/iadr/ethics.html

Guidelines and resources –www.who.int/ethics/research/en/

Harvard School of Public Health, ethical issues ininternational health research course –www.hsph.harvard.edu/bioethics/

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120APPENDIX C

Association for Dental Education in Europe: Profileand Competences for the European Dentist –adee.dental.tcd.ie/ec/repository/EJDEProfile—-final—formatted-for-web-.pdf (2004)

Domain I: Professionalism

MAJOR COMPETENCE: PROFESSIONAL BEHAVIOR

On graduation, a dentist must have contemporaryknowledge and understanding of the broader issuesof dental practice, be competent in a wide range ofskills, including research, investigative, analytical,problem-solving, planning, communication,presentation and team skills and understand theirrelevance in dental practice.

Specifically, a dentist must:

SUPPORTING COMPETENCES:

1.1) Be competent to display appropriate caringbehaviour towards patients.

1.2) Be competent to display appropriate professionalbehaviour towards all members of the dental team.

1.3) Have knowledge of social and psychologicalissues relevant to the care of patients.

1.4) Be competent to seek continuing professionaldevelopment (CPD) allied to the process of continuingeducation on an annual basis, in order to ensure thathigh levels of clinical competence and evidence-basedknowledge are maintained. This should be readilydemonstrated with the use of a CPD logbook.

1.5) Be competent to manage and maintain a safe


121working environment with special reference and to allaspects of cross-infection control.

1.6) Have knowledge and awareness of theimportance of his/her own health and its impact onthe ability to practise as a dentist (ergonomics andoccupational diseases).

1.7) Be competent to deal with other members of thedental team with regard to health and safety.

MAJOR COMPETENCE: ETHICS AND JURISPRUDENCE

The graduating dentist must have knowledge andunderstanding of the moral and ethicalresponsibilities involved in the provision of care toindividual patients and to populations, and haveknowledge of current laws applicable to the practiceof dentistry. In particular, the graduating dentist must:


1.8) Have knowledge of the ethical principles relevantto dentistry and be competent at practising withpersonal and professional integrity, honesty andtrustworthiness.

1.9) Be competent at providing humane andcompassionate care to all patients.

1.10) Have knowledge and understanding of patients’rights, particularly with regard to confidentiality andinformed consent, and of patients’ obligations.

1.11) Have knowledge and awareness that dentistsshould strive to provide the highest possible quality ofpatient care at all times.

1.12) Be competent at selecting and prioritisingtreatment options that are sensitive to each patient’s

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122individual needs, goals and values, compatible withcontemporary therapy, and congruent with acomprehensive oral health care philosophy.

1.13) Acknowledge that the patient is the centre ofcare and that all interactions, including diagnosis,treatment planning and treatment, must have thepatient’s best interests as the focus of that care.

1.14) Be competent in respecting patients andcolleagues without prejudice concerning gender,diversity of background and opportunity, languageand culture.

1.15) Be competent at recognising their ownlimitations and taking appropriate action to help theincompetent, impaired or unethical colleague andtheir patients.

1.16) Have knowledge of the judicial, legislative andadministrative processes and policy that impact allaspects of dentistry.

1.17) Be competent in understanding audit andclinical governance,

Domain II: Communication andInterpersonal Skills

MAJOR COMPETENCE: COMPETENT INCOMMUNICATING

The graduating dentist must be competent incommunicating effectively with patients, their familiesand associates, and with other health professionalsinvolved in their care. In particular, he or she must:


123SUPPORTING COMPETENCES:

2.1) Establish a patient-dentist relationship that allowsthe effective delivery of dental treatment.

2.2) Have knowledge of behavioural sciences andcommunication including behavioural factors (incl.factors as ethnicity and gender) that facilitate thedelivery of dental care and have knowledge of therole of psychological development in patientmanagement.

2.3) Be competent in identifying patient expectations(needs and demands) and goals for dental care.

2.4) Be competent at identifying the psychologicaland social factors that initiate and/or perpetuatedental, oral and facial disease and dysfunction anddiagnose, treat or refer, as appropriate.

2.5) Be competent at sharing information andprofessional knowledge with both the patient andother professionals, verbally and in writing, includingbeing able to negotiate and give and receiveconstructive criticism.

2.6) Be competent at applying principles of stressmanagement to oneself, to patients and to the dentalteam as appropriate.

2.7) Be competent at working with other members ofthe dental team.

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124Domain VII: Health Promotion

MAJOR COMPETENCE: IMPROVING ORALHEALTH OF INDIVIDUALS, FAMILIES AND GROUPSIN THE COMMUNITY

The new dentist must be competent at improving theoral health of individuals, families and groups in thecommunity. Specifically, he or she must:


7.1) Be competent in applying the principles of healthpromotion and disease prevention.

7.2) Have knowledge of the organisation andprovision of healthcare in the community and in thehospital service.

7.3) Be competent in understanding the complexinteractions between oral health, nutrition, generalhealth, drugs and diseases that can have an impacton oral health care and oral diseases.

7.4) Have knowledge of the prevalence of thecommon dental conditions in the country oftraining/practice.

7.5) Have knowledge of the importance ofcommunity-based preventive measures.

7.6) Have knowledge of the social, cultural andenvironmental factors which contribute to health orillness.


125General Dental Council (U.K.): The First Five Years:A Framework for Undergraduate Dental Education –www.gdc-uk.org/News+publications+and+events/Publications/Guidance+documents/The+First+Five+Years.htm

LAW, ETHICS AND PROFESSIONALISM

63. Dental students should understand the legal andethical obligations of registered dental practitioners,the permitted activities of PCDs and the regulatoryfunctions of the GDC. Every student should be awareof the principles and practices involved in dentalaudit, of the ethical responsibilities of the dentalprofession in clinical investigation and research and inthe development of new therapeutic proceduresincluding the concept of risk assessment andmanagement. The ethical aspects of professionalrelationships should also be drawn to students’attention, and their reconciliation with personal andpublic morality. Dental students need to have somefamiliarity with the specific requirements ofcontemporary general dental practice, includingreference to relevant regulations and the valuable roleplayed by the dental defence organisations. Studentsshould recognise and act upon the obligations ofmembership of the dental profession, as outlined inthe GDC’s publication Maintaining Standards. TheDisability Discrimination Act and the Human RightsAct are examples of how this area is rapidly changingand influencing many facets of professional life.Issues of professionalism such as student behaviourwith respect to alcohol and the use of recreationaldrugs should be addressed.

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12664. The legal basis under which patients are treatedshould be discussed and the ethical responsibilitieswhich the student assumes under thesecircumstances examined. No student should proceedto treat patients without a proper understanding ofthese matters, especially consent, assault, duty of careand confidentiality. The legal requirement to maintainfull, accurate clinical records should also beappreciated by the student.

65. Students should understand the importance ofcommunication between practitioner and patient.This helps to develop attitudes of empathy andinsight in the student and provides the opportunityfor discussion of contemporary ethical issues.Students should also be encouraged to understandtheir own responses to work pressures and theirmanagement. There may be opportunities forintegrated or complementary teaching with otherbasic sciences on topics such as pain, stress andanxiety, and with clinical specialties on topics such associal class, poverty, and the needs of children andthe elderly.

66. There should be guidance on the key ethical andlegal dilemmas confronting the contemporarypractitioner and on the basics of employment law.Students should also have opportunities to considerthe ethical and legal dimensions of day to daypractice. For example, students should learn how to:

• handle patient complaints;

• ensure that patients’ rights are protected;

• provide appropriate care for vulnerable patients;

• confront issues concerning treatment planning andthe practice of dentistry and dentistry within the


127context of limited financial resources;

• maintain confidentiality;

• deal with gender and racial issues;

• deal with colleagues failing their professionalresponsibilities.

67. Students should also understand the practical andethical considerations that should be taken intoaccount when seeking patients’ consent, such as:

• providing sufficient information about conditionsand possible treatments;

• responding to questions;

• knowing who is the most appropriate person togive consent;

• gaining consent in emergencies;

• establishing a patient’s capacity to give consent;

• statutory requirements that may need to be takeninto account;

• gaining valid consent.

68. Ethical and safety issues should form animportant part of the ‘Introduction to ClinicalDentistry’ element of the curriculum. The coursematerial must not ignore the moral and ethicaldilemmas which confront the dentist in practice.

69. The ethical approach to patient care willsubsequently be reinforced in the clinical dentalcourse, being broadened as time passes toencompass the legal obligations of the practitioner. Inthat regard, special attention must be paid to theregulatory mechanisms of dentistry, particularly asthey apply to general dental practice. Stress should beplaced on good record keeping.

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128Association of Canadian Faculties of Dentistry:Competencies for a Beginning Dental Practitioner inCanada – www.acfd.ca/en/publications/ACFD-Competencies.htm

A beginning dental practitioner in Canada must be competent to:

1. recognise the determinants of oral health inindividuals and populations and the role of dentistsin health promotion, including the disadvantaged.

2. recognise the relationship between general healthand oral health.

3. evaluate the scientific literature and justifymanagement recommendations based on the levelof evidence available.

4. communicate effectively with patients, parents orguardians, staff, peers, other health professionalsand the public.

5. identify the patient’s chief complaint/concern andobtain the associated history.

6. obtain and interpret a medical, dental andpsychosocial history, including a review of systemsas necessary, and evaluate physical or psychosocialconditions that may affect dental management.

7. maintain accurate and complete patient records ina confidential manner.

15. recognise signs of abuse and/or neglect and makeappropriate reports.


129

20. discuss the findings, diagnoses, etiology, risks,benefits and prognoses of the treatment options,with a view to patient participation in oral healthmanagement.

22. present and discuss the sequence of treatment,estimated fees, payment arrangements, timerequirements and the patient’s responsibilities for treatment.

23. obtain informed consent including the patient’swritten acceptance of the treatment plan and anymodifications.

45. apply accepted principles of ethics andjurisprudence to maintain standards and advanceknowledge and skills.

47. demonstrate professional behaviour that isethical, supercedes self-interest, strives forexcellence, is committed to continuedprofessional development and is accountable toindividual patients, society and the profession.

The (USA) Commission on Dental Accreditation:Standards for Dental Education Programs –www.ada.org/prof/ed/accred/standards/predoc.pdf

Ethics and Professionalism

2-20 Graduates must be competent in applyingethical, legal and regulatory concepts to the provisionand/or support of oral health care services.

2-21 Graduates must be competent in the applicationof the principles of ethical reasoning and professional

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130responsibility as they pertain to patient care andpractice management.

2-22 Graduates must recognise the role of lifelonglearning and self-assessment in maintainingcompetency.

APPENDIX D - STRENGTHENING ETHICSTEACHING IN DENTAL SCHOOLS

Some dental schools have very little ethics teachingwhile others have highly developed programs. Even inthe latter ones, however, there is always room forimprovement. Here is a process that can be initiatedby anyone, whether dental student or facultymember, who wants to strengthen the teaching ofdental ethics in his or her institution.

1. Become familiar with the decision-making structurein the institution

• Dean

• Curriculum Committee

• Faculty Council

• Influential faculty members

2. Seek support from others

• Students

• Faculty

• Key administrators

• National dental association

• National dental regulatory body

3. Make a strong case

• Association for Dental Education in Europe: Profileand Competences for the European Dentist


131• General Dental Council (U.K.): The First Five Years:

A Framework for Undergraduate Dental Education

• Association of Canadian Faculties of Dentistry:Competencies for a Beginning Dental Practitioner in Canada

• The (USA) Commission on Dental AccreditationStandards for Dental Education Programs

• Examples from other dental schools

• Research ethics requirements

• Anticipate objections (e.g., overcrowded curriculum)

4. Offer to help

• Provide suggestions for structure, content, facultyand student resources

• Liaise with other dental ethics programmes, the FDI, etc.

5. Ensure continuity

• Advocate for a permanent dental ethics committee

• Recruit younger students

• Recruit additional faculty

• Engage new faculty and key administrators

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About the FDI World Dental FederationThe FDI World Dental Federation is the worldwide,authoritative and independent voice of dentistry. Withmore than 130 national dental associations in more than125 countries around the world, it represents nearly onemillion dentists internationally.

For more information about the FDI World DentalFederation, please visit www.fdiworldental.org

FDI World Dental Federation13 Chemin du Levant

l’Avant CentreF-01210 Ferney-Voltaire

France

Tel : +33 4 50 40 50 50Fax : +33 4 50 40 55 55

Website : www.fdiworldental.orgEmail : [email protected]

5051 fdi dental ethics book - 4everlearning.com · written by john r. williams, ph.d. ... it is a...

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