ETHICS FOR THE DENTAL INDUSTRY
The purpose this course is to heighten ethical and professional responsibility, promote ethical conduct and professionalism in dentistry, advance dialogue on ethical issues, and stimulate reflection on common ethical problems in dental practice. We will review the health care principles used in dentistry to help identify, clarify and support choices when faced with an ethical problem or dilemma. Much of this material is provided by Crest +Oral-B, a trusted resource for dental professionals.
Every dentist and dental hygienist is granted special rights and responsibilities when they earn the credentials to become an oral health care professional. A professional person is one who has completed a specialized program of knowledge and gained a license in a discipline that is of value to society.
In the corporate world, success is often measured by financial gain. For the health care professional, the motive of the patient’s welfare is placed above the profit motive. Because of this service motive, society has granted to the health care professional a certain status that carries prestige, power, and the right to apply that special knowledge and skill.
When patients seek care from any health care provider, they expect to receive the very best care from a professional and ethical practitioner. The health care services provided involve technical skill, appropriate knowledge, critical judgment, and most importantly, empathy and caring. It is the essence of caring that patients perceive and to which they respond. In the delivery of health care, trust is the critical foundation for the relationship that develops between the person seeking services—the patient—and the health care provider—the professional. The patient is aware that the health care provider has certain knowledge and skills. However, it is the caring the patient seeks that gives the provider of dental services the greatest opportunity for professional service and satisfaction. An understanding of ethical issues and an awareness of the ethical obligations inherent in the provision of health care will enable the dental professional to deal effectively with patients and their community.
ETHICAL DILEMMAS IN ORAL HEALTH CARE
The two main goals involved in ethics are the ability to discern right from wrong and the commitment to act on a decision. As clinicians providing care and services, every dentist and dental hygienist will be faced with many choices, problems and dilemmas. Some of these choices will be simple issues of right and wrong, whereas others may be ethical dilemmas that require careful decision making. The clinician must be aware of the ethical issues that can arise and be prepared to take appropriate action when necessary.
A useful tool the clinician can refer to is the appropriate code of ethics for their discipline. For the dentist, it is the American Dental Association’s (ADA) Principles of Ethics and Code of Professional Conduct and for the dental hygienist it is the American Dental Hygienists’ Association (ADHA) Code of Ethics for Dental Hygienists.
Codes of ethics are the written standards to which health care professionals agree to adhere before society, which grants certain privileges to these groups. Among these privileges is societal trust and self-regulation. Once an individual has gained the necessary professional knowledge and skill and acquired a professional license, he or she is accorded professional status. The responsibility that goes with this status is to uphold the principles and core values of the professions. Principles help address the moral question: What ought a person to do in a troublesome situation? More specifically, what is good, right, or proper for a person to do in this situation? Normative principles provide a cognitive framework for analyzing moral questions and problems.
The following will explore terms and principles that are considered to be the foundation of ethics.
The principle of universality assumes that, if one individual judges an action to be right or wrong in a given situation, other people considering the same action in the same situation would make the same judgment.
The principle of complementarity assumes the existence of an obligation to justice and basic human rights. It requires us to act toward others in the same way they would act toward us if roles were reversed. In all relationships, it means considering the values and perspective of others before making decisions or taking actions affecting them.
This principle expresses our concern for the bond between individuals, the community, and society in general. It leads us to preserve natural resources and inspires us to show concern for the global environment.
Responsibility is central to our ethics. We recognize that there are guidelines for making ethical choices and accept responsibility for knowing and applying them. We accept the consequences of our actions or the failure to act and are willing to make ethical choices and publicly affirm them.
Nonmaleficence is the principle that actions or practices are right insofar as they avoid producing bad consequences. This is the foundation of all health care and describes the first obligation that every health care provider embraces — do no harm. In Latin the term is primum non nocere which means first, do no harm. Patients who seek dental services place themselves in the care of another person and, at a minimum, should expect that no additional harm will result from that act. The patient grants the clinician the privilege of access to a portion of his or her body for an explicit purpose, a privilege founded in trust. Fundamental to that trust is that the health care provider will do no harm to the patient.
The Hippocratic Oath requires the health care provider promise to keep the sick from harm and injustice. In reference to nonmaleficence, the ADA Principles of Ethics and Code of Professional Conduct, states “the principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle, the dentist’s primary obligations include keeping knowledge and skills current, knowing one’s own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate.” For example, practitioners are required to maintain their level of knowledge and skill through participation in appropriate continuing education programs. Thus a dentist who has not performed an endodontic procedure since graduation from dental school 20 years ago would be expected to refer patients to a colleague for root canal therapy. Likewise, a dental hygienist also has an obligation to stay up-to-date with the changing standards of care in the profession. A hygienist who is unfamiliar with local anesthesia techniques should refer or defer performing that service until achieving competency.
Over time non-maleficence has evolved to include preventing and removing harm. Therefore, health care providers have an obligation to do no harm as well as to prevent harm. Prevention of harm clearly is a domain of dentists and dental hygienists as great emphasis is placed on educating patients about preventing dental caries and periodontal disease.
Beneficence is the principle that actions and practices are right insofar as they produce good consequences.5 Whereas nonmaleficence is concerned with doing no harm to a patient, beneficence requires that existing harm be removed. Beneficence focuses on “doing good” for the patient. Doing good requires taking all appropriate actions to restore patients to healthy state. Health care providers, based on their knowledge and skill, use all reasonable means to benefit the patient. Dentists and hygienists have acquired a body of knowledge and corresponding skills that make them uniquely qualified to help identify patient needs and recommend and provide services to address those needs. Thus, their unique knowledge and skills allow them to benefit the patient by removing existing harm and assisting in the prevention of future harm.
Beneficence and nonmaleficence often are linked because they are both founded in the Hippocratic tradition, which requires the physician to do what will best benefit the patient. This is a consequentialist approach. Meeting the requirement to do what the physician believes will best benefit the patient and implies the need to conduct a consequence analysis to determine the best possible outcome for the patient. Beneficence is found in all health care codes. By choosing to become a dentist or dental hygienist, an individual assumes a responsibility to help others and professes to be a part of a profession. This means that actions, behaviors, and attitudes must be consistent with a commitment to public service. This commitment to help and benefit others defines the healing professions and sets them apart from other occupations.
Any individual who is in a position to promote good for the benefit of others, such as health care professionals, fails to increase the good of others is considered morally wrong. The purpose and existence of biomedical research, public health policies and programs, and preventive medicine are the formalized aspects of this part of health care. Through various federal, state, and community-based activities, society attempts to meet this need for the good of the general public. The promotion of good becomes challenging when good is defined according to differing values and belief systems. The teaching of careful oral hygiene self-care to maintain health and function is an example of promotion of good to many people. However, the removal of all carious teeth to eliminate pain and suffering may be considered promoting good to other individuals. In public health programs, the appropriation of limited resources to meet the medical and dental needs of a given population can be a complex and frustrating exercise. It is also part of being a health care professional, a leader who advocates for the betterment of society.
Autonomy is the principle that embraces respect for persons, the ability to be self-governing and self-directing. An autonomous person chooses thoughts and actions relevant to his or her needs, independent from the will of others. In health care autonomy gives rise to the concept of permitting individuals to make decisions about their own health, which is the heart of many ethical dilemmas that occur in dentistry.7 All health care professionals must respect the autonomy of patients and properly inform them about all aspects of the diagnosis, prognosis, and the care being provided. Because dentists and dental hygienists have a wide range of knowledge and skills, they must fully and adequately explain the parameters of the services that can be performed as well as the consequences of performing or not performing those services.
Unlike nonmaleficence and beneficence which arise from the Hippocratic traditions, autonomy concerns arose much later in the 20th century. The application of autonomy is based on respect for persons which holds that the health care professional has a duty to allow patients to make decisions about actions that will affect their bodies. This also includes the duty to provide patients with all the unbiased information they would need to make a decision about treatment options.
Conflict can arise around this concept when what the dentist and/or hygienist believes is in the best interest of the patient differs from what the patient desires. Sometimes what the professional believes is best for the patient is not what the patient elects to do. As long as the patient selects from treatment options that are consistent with accepted standards of care, the professional may ethically act on the patient’s choice. However, the professional practitioner also has the autonomy to not provide a service requested by the patient if that service is in conflict with the standards of patient care. For example, refusing a patient’s request to extract all healthy teeth would be ethical even though that decision would conflict with the patient’s autonomy. Dentists and hygienists will avoid doing harm to a patient even if the patient is exercising autonomy by asking to receive a potentially harmful treatment or service.
The principle of justice is concerned with providing individuals or groups with what is owed, due, or deserved. Some view justice as a duty for health care providers. The foundation of justice has frequently been described as the principle of equality; likes should be treated alike, equals should be treated as equals, and unequals treated as unequals. The obvious problem in this approach is that some mechanism or criteria must determine who is equal or unequal. Fundamental to the principle of justice is an effort to treat people who have similar needs in a similar or identical manner. All patients who seek treatment for the prevention of periodontal disease should receive the same level of care and attention from the dentist or dental hygienist regardless of personal or social characteristics. Naturally, this approach does not take money into consideration and that is unrealistic. Placing money aside is easy in a discussion but difficult in application in a capitalistic society. Regardless of age, gender, social status, religion, or other distinguishing factors, each person should be entitled to the same oral health care options when a similar health care need exists. That would be just.
Justice in dentistry is most often discussed in terms of public policy issues, referred to as distributive justice. Every society must address the problem of how its resources will be distributed because every society has a scarcity of resources. Resources are scarce whether referring to materials, specially trained individuals, money, or time. Distributive justice is concerned with the allocation of resources in large social systems. Policymakers must confront the issue of how society distributes its resources. This has implications for national health care policy and is a complex issue. Questions immediately arise around what kind of treatment will be offered, who will provide the treatment, and who will be eligible to receive the treatment?
If resources were unlimited, the problem of just allocation would be minimal. Unfortunately, that is not the reality of the world. Choices must be made, benefits and burdens must be balanced, and resources justly distributed. A lofty goal for most organized societies would be the just application of health care. However, no legal mandate exists for dental care to be available to all persons, and decisions are made daily according to the ability of the patient to pay for the services rendered. Thus the provision of dental care is applied unequally. People who present for treatment are, for the most part, are granted access to care based on their economic ability and not their dental needs.
The question of who should provide dental care when an economically impoverished individual with no financial means is in need of treatment is difficult to answer. Many dentists and dental hygienists provide charitable services on a regular basis, either in a private practice office or through participation in a community-based service clinic, because of their recognition of their obligation to serve society. Many dental public health practitioners and leaders consistently call for the profession to make oral health a much higher priority for federal and state decision makers.
Complementarity is a term that is defined as doing the greatest good for the greatest number of persons. This term is closely aligned with justice and good stewardship of resources. Any discussion about the use and application of public policy is an example of complementarity, as is consideration of culture and language in health care services.
Veracity is defined as being honest and telling the truth and is related to the principle of autonomy. It is the basis of the trust relationship established between a patient and a health care provider. Veracity is what binds the patient and the clinician as they seek to establish mutual treatment goals. Patients are expected to be truthful about their medical history, treatment expectations, and other relevant facts. Clinicians, for their part, must be truthful about the diagnosis, treatment options, benefits and disadvantages of each treatment option, cost of treatment, and the longevity afforded by the various treatment options. This allows patients to use their autonomy to make decisions in their own best interest.7 The obligation of veracity, based on respect for patients and autonomy, is acknowledged in most codes of ethics, including the codes of the ADHA and the ADA.
Lying to a patient does not respect the autonomy of the patient and can compromise any future relationships the patient may have with health care providers. Because relationships are built on trust, lying, even little “white lies,” easily erodes trust. Benevolent deception is the name given to the practice of withholding information from a patient because of the clinician’s belief that the information may harm the individual. This practice is in the tradition of the Hippocratic oath but is not supported by most codes of ethics and then only in extraordinary circumstances. Only a rare case would justify deceit in the dental setting. The interactive health care relationship between patient and clinician functions most effectively when both parties are truthful and adhere to all promises made in the process.
VALUES AND CONCEPTS IN DENTISTRY AND DENTAL HYGIENE
An ethical dilemma occurs when one or more ethical principles are in conflict. Several values and related rules support the principles of ethics and help the problem solving process when a clinician is making ethical decisions. Values and concepts presented are founded in ethical principles and the theory upon which those principles are based. Occasionally these values or concepts might add to the complexity and conflict of the situation, but the goal is to add clarity when resolving ethical issues. These rules then, along with the supporting principles and values, can provide the clinician guidance in the decision-making process.
These terms and concepts are informed consent, confidentiality, paternalism, and prima facie duty and are rooted in the health care principles.
Informed consent is based on the patient exercising autonomy in decision making and has both ethical and legal implications in medicine and dentistry. Informed consent has two parts.
First, it requires that the professional provide the patient with all relevant information needed to make a decision. Second, it allows the patient to make the decision on the basis of the information provided. Informed consent is a process of providing appropriate information to the patient, the process of understanding and assimilating the information, and making the decision.8
Dentists and hygienists must recognize the patient has a right to informed consent as well as a right to make an informed refusal. Respecting the autonomy of individuals as self-determining agents recognizes their right to make their own choices and determine their own destiny. This includes the right for a patient to assess all the information provided by the professional yet still make a choice that is not the one most valued by the professional — informed refusal. Although not as dramatic as life and death decisions made by clinicians in medicine, dental decisions may involve choices that are potentially harmful to the patient.
When patients give their authorization for a procedure or a comprehensive treatment plan, they grant the health care provider informed consent for that treatment. First, the clinician must obtain and document information and disclosure; secondly is the process of interaction and communication, which produces a truly informed decision. Not all individuals have the ability to make informed decisions about their dental health. Children and people who are mentally disabled typically have a parent or caregiver who assumes that function. Depending on the age and capacity of the child, certain choices can and should be discussed with the younger patient, but actual decisions regarding what types of services are rendered must remain the purview of the legal guardian. Informed consent when the patient does not understand because of a language barrier is not possible, and steps must be taken to remedy the situation. The use of a translator, family member, or other communication option must be pursued to ensure the patient fully understands the choices and consequences. To do any less is unethical and illegal. The only exception to this would be if the patient’s life was in danger and an immediate procedure was required to save that life.
An issue related to autonomy and informed consent is the determination of decision-making capacity. Capacity is a clinical term used to describe a person’s ability to understand their health care conditions, treatment options and ability to make their own decisions. For an individual to make informed consent, capacity or competence is a prerequisite. This is a growing concern with an aging population as older adults can exhibit a wide range of cognitive function.
Confidentiality is related to respect for persons and involves the patient exercising his or her autonomy in providing information to the dental professional. Confidentiality is a critical aspect of trust and has a long history of use in health care. The requirement for confidentiality is mentioned in all codes of ethics as well as the Hippocratic oath. Trust is necessary for the exchange of personal and intimate information from the patient to the clinician. A patient has a right to privacy concerning his or her medical and dental history, examination findings, discussion of treatment options and treatment choices, and all records pertaining to dental and dental hygiene care. This privacy extends to the way in which information is gathered, stored, and communicated to other health care professionals. Discussion about a patient’s history or treatment is not to be shared with spouses, family, or friends — to do so is a violation of confidentiality. Information about a patient can be given to other health care professionals with the patient’s permission.
Conflicts and exceptions will arise surrounding the principle of confidentiality. In certain situations legal requirements exist to report diseases that can have an effect on the health of the public, such as sexually transmitted diseases. Reporting suspected child abuse, which is required in most states, is a violation of confidentiality. In dealing with minor children, divulging confidential information to the parents may be necessary to protect the child from harm. This is especially difficult with adolescents, who may or may not be adults according to the legal system. The patient’s right to confidentiality often must be balanced against the rights of other individuals. In any situation the health care provider must communicate to the patient the professional and legal responsibilities that exist for disclosure and work toward assisting the patient as much as possible.
Prima Facie Duty
Prima facie duty is a duty or obligation that must be acted upon before any other considerations enter the picture. Prima facie means “at first glance.” When faced with a conflict of prima facie duties, the clinician is called upon to always act with the stronger duty.4 Sometimes this is examining the rightness or balance of right over wrong. For example, the dentist or dental hygienist who suspects child abuse should place the welfare of the child over the autonomy of the parent. The stronger duty in this instance is the good of the child, not the right of the parent.
One of the core values of the American Dental Hygiene Associations Code of Ethics is patient confidentiality and respect for human beings. Although privacy and confidentiality are separate concepts, protecting the privacy of a patients information is essentially for confidentiality. In order to ensure protection, always remember to only access patient information that is required to perform the assigned job. Healthcare providers all realize that they only have the right to access the information necessary to do their jobs. This has commonly been referred to as need to know information. The HIPAA regulations refer to this as minimum necessary and the same concept holds true only access patient information necessary to perform assigned job duties.
Recently, these regulations have been well publicized and discussed but it is important to remember and to tell the public that dental health professionals have always protected patient confidentiality. Mary Alice Gaston, RDH, MS, editor of The Journal of Dental Hygiene, provided excellent guidance for all dental professionals by stating all we really need to do is use common sense and handle everyones private health information as though it were our own.
In addition to ensuring compliance for HIPAA, dental hygienists play an important role in educating patients on their privacy rights. Most of the time a patient spends in the dental chair is spent with their dental hygienist. Dental hygienists are in the perfect position to educate patients, as well as other office staff about HIPAA.
HIPAA was first developed to make sure that people could not lose their medical coverage when they changed jobs even if they had a pre-existing medical condition. As with many federal laws the bill grew larger and larger. HIPAA today affects almost all health care providers or anyone who is employed anywhere where patient information may be located, including hospitals, clinics, dentists, radiologists and more.
The first goal of the law is to improve the portability and continuity of an individuals health exempt pre-existing conditions as long as the insureds previous health coverage has not lapsed more than 60 days before any new plan takes effect. This part of the legislation became effective in late 1996.
The second goal is to improve dental care administrative efficiency and effectiveness by standardizing electronic transaction processes and setting standards for the major health care code sets. The regulations also define and establish standards and national databases for health care providers, health plans and employers.
The third goal of HIPAA is to strengthen the health care industrys ability to combat waste and fraud while protecting and securing patient confidentiality. You are surrounded by patient data information and it is your responsibility to keep it private and confidential. If not, your employer and you can face financial and criminal penalties.
How the HIPAA Privacy Rule Affects You?
The HIPAA Privacy Rule, the first major HIPAA regulation, became effective April 14, 2003. It requires that almost all providers who file claims for reimbursement meet this required date or face significant fines and other penalties. As the original HIPAA regulations to assure patient insurance portability were developing, congress urged healthcare organizations to become more efficient through computerization. But, before doing so, they expanded the regulations to make sure that legal safeguards were added to protect patient information from prying eyes. This is the basis of the privacy rule.
A Covered Entity
Basically, any organization covered by HIPAAs regulations is a Covered Entity. You see HIPAA regulations cover much more than healthcare providers. In fact, all health plans and payers of healthcare services are also covered by HIPAA. Covered Entities include hospitals, clinics, dentists, laboratories, mental health providers, medical imaging services, and just about everyone that delivers any form of health care then files a claim electronically and gets paid or reimbursed for their services.
HIPAA is quite serious about these regulations. The penalties for violating the Privacy Rule can range from a simple fine all the way up to 10 years in jail plus a $250,000 fine.
Protected Health Information
HIPAA Privacy requirements are based on the concept of Protected Health Information or PHI. This is medical information that contains any data element that can be used to link a past, present or future medical condition to an individual. The regulation lists 19 such elements and includes items such as a patient’s name, address, birth date, telephone or fax number, employer, license number, etc.
Do You Know Your Organizations HIPAAs Policies and Procedures?
Section 164.530 of the Privacy regulation makes it clear that a covered entity must implement policies and procedures with respect to PHI (Personal Health Information) that are designed to comply with the standards. In other words, your organization must have a set of written policies and procedures when it comes to protecting PHI (Personal Health Information) and you need to read them.
SOLVING ETHICAL PROBLEMS
The first step in analyzing ethical issues is obvious, but not always easy: Get the facts. Some issues create controversies simply because we do not bother to check the facts. But having the facts is not enough. Facts by themselves only tell us what is; they do not tell us what ought to be. Many times it is necessary to consult with other professionals. It is important to discuss only what it is relevant and only with those in a position to offer guidance.
The presentation of principles and values is to provide the precepts that are the underpinnings of codes of ethics used in dentistry. The basic principles of nonmaleficence, beneficence, autonomy, justice and veracity along with the values of informed consent, confidentiality and parentalism are presented and discussed with the goal of identifying and applying these guidelines when analyzing an ethical dilemma or pondering a difficult choice between right and wrong.
Please follow the links below to the Code of Ethics for the American Dental Association and the American Dental Hygienist Association.
American Dental Hygienist Association Code of Ethics