FDI Dental Ethics Manual

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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. DentistsRole 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- Whats special about dentistry? .......................... 22- Whats 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 - Whats 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- Whats 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 OReilly, 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 FDIs 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 FDIs 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 patientshealth 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. Michle 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 ofwhen 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 Manuals 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), rightand 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 doesnt matter.

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18Ethics 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.

Whats 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 publicsrespect 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 dentistsadvice 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.

Whats 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 persons distress, is essential for thepractice of dentistry. In order to deal with the patientsproblems, 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 dentists 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


27

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 ones 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 thecountrys approach to health law, these standardsmay have legal status.

The dental professions 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 patients 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 FDIs 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 ones 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 ones desire; what iswrong is what feels wrong or frustrates ones 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 allones 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 Gods 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.

Whats 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 dentists 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 (childrens 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 torefuse to accept patients into their practice or denydental service to patients because of the patientsrace, 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 dentists 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. Adentists 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 patientsdignity and values but goes further in acknowledgingand responding to the patients vulnerability in theface of illness and/or disability. If patients sense thedentists 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 Associations 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 patients oralhealth is not jeopardised in the process.

There are many reasons for a dentist wanting toterminate a relationship with a patient, for example,the dentists moving or stopping practice, thepatients refusal or inability to pay for the dentistsservices, dislike of the patient and the dentist foreach other, the patients refusal to comply with thedentists 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 thedentists duty to treat all patients equally. Accordingto the FDIs 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 ones 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 dentists 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 dentistsopinion, not in the patients 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 ones 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.


55

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 apatients refusal of a recommended treatment doesnot mean that the patient is incompetent; it may bethat the patient has failed fully to understand thedentists recommendation and the reasons for it.Likewise, patients are not necessarily competentbecause they readily agree to the dentists 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 FDIs 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 personsprivate 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 theminformation 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 Councils Principles ofPatient Confidentiality summarises the dentistsresponsibilities 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 thepatients 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 dentistsdental assistants, receptionists, etc.require access toa patients 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 thepatients benefit. As the FDIs 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 thedentists presence to self-report, or that the dentistobtain the parents 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 patients

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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 thepatients 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 wont 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 childsage 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.Continui

FDI Dental Ethics Manual

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