By Marcy Ortiz, RDH, BA
Ethics is a difficult concept to define because it is viewed very differently depending on the particular dilemma. Doing the right thing when confronted with a difficult circumstance is one way to define ethical behavior. Ethical is also defined as “maximizing the good while minimizing the bad,”1 or according to Merriam Webster, ethics is “the discipline dealing with what is good and bad and with moral duty and obligation.”2 Another definition is being professional and being able to deal with morally perplexing situations.3 Regardless of the definition, it is not always easy to do the right thing in a given circumstance because the right choice may not always benefit the hygienist’s best interests.
Dental professionals, including dental hygienists, are confronted daily with difficult choices that require decisive action and judgment calls for which careful deliberation is required.4 To enable a fair consideration for all parties, certain guidelines or health-care principles are available to “weigh the potential consequences (benefits and harm) and the rights and general welfare of all involved.”4 The four principles of health-care ethics are autonomy, beneficence, nonmaleficence, and justice5 (see chart 1). “Beneficence and nonmaleficence are often linked because both are found in the Hippocratic tradition, which requires the physician [dentist or hygienist] to do what will best benefit the patient.”1 It is important for the dental hygienist to consider all four ethical principles when weighing a moral dilemma regarding patients.
An ethical dilemma occurs when one of the above principles conflicts with another.1 For example, a patient decides he or she wants to save money by refusing X-rays for the fourth year in a row. The patient is exercising his or her autonomy. However, the hygienist realizes this puts him or her in an ethical dilemma. Not taking X-rays for so long is a form of nonmaleficence, and it does not benefit the patient and can harm the patient due to undetected periodontal disease, decay, pathology, and more.
Practicing in the dental profession, dental hygienists see an array of ethical concerns while treating patients. These dilemmas can vary depending on the type of practice, specialty, and age of patients in the practice. However, there are some ethical areas that are more common and will be highlighted here. The specific case examples that follow relate to the ethical principles presented in chart 1, and values that correspond to these principles in our profession.
Paternalism vs. informed consent
Paternalism is the practice of acting as the “parent,” which is taking it upon oneself to make decisions for the patient. Years ago the “doctor knows best” approach regarding treatment was common. The doctor merely picked a course of treatment he or she thought was best for the patient. Of course, paternalism is not acceptable today because it eliminates patients’ right to choose the treatment they feel is right for them, even if their choice is not what the doctor feels is best.
Here is an example of paternalism. The patient is given a treatment plan of extracting a painful tooth and fabricating a three-unit bridge for tooth replacement. Due to the patient’s age, the dentist feels this is the easiest approach so the tooth will not give the patient any problems in the future. In this case, there is no mention of possible endodontic treatment or replacing the extracted tooth (if extraction is required) with an implant. Paternalism violates this patient’s autonomy and self-determination, and ethically involves nonmaleficence due to not giving the patient the right to informed consent; thus, paternalism is the opposite of informed consent. This patient did not have all the information needed to make an informed decision for care.
Informed consent is highly recommended for today’s progressive medical and dental treatment. This allows for patient autonomy, self-determination, and beneficence, thus avoiding paternalism. Dental offices, like medical offices, are able to “provide patients a financial estimate for prostheses and other treatments,” and even have patients sign a document acknowledging their financial agreement.6 This agreement helps patients understand their alternatives regarding treatment. The agreement may even state estimates relating to each treatment option.
Informed consent requires opening the lines of communication between provider (dentist or hygienist) and patients. The provider needs to make sure patients understand their options, and patients then acknowledge they have all the information, benefits, and risks along with their financial obligation. Interestingly, many providers do not take into account the pain people will experience as an ethical problem — “for some, pain still seems to be only a technical problem solved by treatment.”6 Pain is an ethical concern for patients and should be incorporated into the informed consent information when presenting options for patients. Pain can have a substantial effect on the treatment options patients consider.
In today’s economic climate, one would assume overselling or overtreatment would be more widespread than supervised neglect, but surprisingly, supervised neglect does occur, even in good dental practices. There are conditions when patients slip through the cracks, or long-term patients become so comfortable in a practice they’re allowed a great amount of autonomy, which becomes a detriment to their best interest. Beneficence now becomes a concern. To illustrate supervised neglect, two case examples show common dental care dilemmas hygienists experience — periodontal disease treated conservatively in high-risk patients, and radiographic refusal. Both these situations result in cause for disagreement between the dental hygienist and his or her employer in which an ethical dilemma will ensue.
1) A long-term periodontal patient is currently receiving periodontal maintenance recalls every three months. He is a diabetic patient with normal A1C scores. After receiving root planing, periodontal pocketing is still out of control, with depths ranging from 4 mm to 9mm. The hygienist is beyond frustrated because she feels she is in over her head. The dentist does not think the patient will consider a periodontal referral due to his age and advanced periodontal condition; thus no referral is offered (paternalism, nonmaleficence). In this example, nonmaleficence is the primary ethical principle at issue. Nonmaleficence is included in the ADA Code of Professional Conduct description as doing no harm and “… knowing one’s limitations and when to refer to a specialist or another professional.”7
What is the hygienist to do? She discusses the patient’s options during a few maintenance appointments and stresses he will eventually lose some teeth if further treatment is not considered. She gently explains she has done everything she can in her scope of practice, and yet the periodontal disease is still active. Not surprisingly, this patient did not want to lose his teeth and agreed to see the periodontist for further treatment (informed consent in action). Unfortunately, the patient did lose several teeth that had advanced periodontal pocketing, but he is now receiving active periodontal therapy via the periodontist (beneficence).
2) Radiographic refusal is a huge problem in many practices due to the economy and lack of insurance. This case involves a patient who has refused any type of X-ray since 2005. Yes, that is seven years without an X-ray! The patient merely signed a release and spent the money he saved on his next vacation. During one prophylaxis recall, he stated he could not receive X-rays because he just paid for his rental car to the Bahamas, and besides, he did not have insurance! The dentist did not push the patient to consider X-rays and had no intention of dismissing him from the practice. The patient was practicing his autonomy; however, the dentist was not considering beneficence for this patient.
This patient developed a moderate amount of calculus and a suspicious area on the lingual of tooth No. 31 (part of a three-unit bridge). The treating hygienist explained, once again, the need for X-rays. She stressed that she was working blind regarding subgingival calculus detection and removal without the aid of any current X-rays, and “who really knows what is occurring under No. 31?” Reluctantly, the patient agreed to an FMX the next visit. Luckily, his calculus formation is now under control, with no subgingival evidence on the X-rays. However, tooth No. 31 is not so lucky.
The tooth is completely decayed from the gingival margin, under the crown, and it continues deep into the apices. Surprisingly, the patient has no pain. He asked about his treatment options for this decayed tooth, which will cost thousands to replace with an implant, as it requires extraction. If the decay had been detected earlier via routine X-rays, a new three-unit bridge could have been fabricated because this tooth had enough bone to warrant a new bridge.
The patient feels awful, and the dentist feels terrible for the patient, but he does not see that this as a case of supervised neglect. Instead, the dentist puts the blame on the patient for refusing the care offered. It is true that the ADA ethical code’s first principle is “patient autonomy” [it states in part], “professionals have a duty to treat the patient according to the patient’s desires, within the bounds of accepted treatment.”8 Seven years without X-rays is not within the bounds of accepted treatment. Nonetheless, patients do have an involvement in their care, and if the provider feels a patient’s refusal of X-rays is limiting diagnostic capabilities, a dentist “may consider discussing with the patient options regarding consultation with or treatment by another dentist.”8
Model for working through ethical dilemmas
These ethical dilemmas, though typical, are still difficult to work through in each situation. Patients deserve to exercise their self-determination, but not at the risk of their dental health. Dental professionals must weigh options that allow a patient’s autonomy while exercising beneficence and avoiding maleficence. Exercises or decision models can help work through each dilemma to reach an ethical decision. An effective model for dental health-care professionals to evaluate and solve ethical dilemmas is illustrated in “Ethics and Law in Dental Hygiene” (2010) by Phyllis L. Beemsterboer. Beemsterboer outlines the following six-step decision-making model.1
- Identify the ethical dilemma or problem
- Collect information
- State the options
- Apply the ethical principle to the options
- Make the decision
- Implement the decision
The first step, identify the ethical dilemma, is to pinpoint the ethical problem. Do you have a legitimate ethical dilemma? Are principles in conflict? State the specific conflict, then evaluate and apply the specific health-care principles that conflict with one another. Without a conflict of principles, there is no ethical problem but merely a right or wrong type of predicament.
Step two, collect specific information, is critical to the case in question. The information can be specific statements of fact and can come from a variety of sources pertaining to how the conflict began, how it proceeded, and what parties are involved. Information collection is necessary to make a balanced ethical decision.
Step three, state the options, is a step-by-step process or analysis to judge each option and the consequences related to each option. Troubleshoot as many options and their full consequences before proceeding to the next step.
In step four, apply the ethical principles to the options. Beemsterboer recommends, “State how each alternative will affect the ethical principle or rule by developing a list of pros and cons.”1 List each principle violated while considering specific values such as supervised neglect, informed consent, paternalism, and more. Show the pros and cons of each option and its consequences discussed in step three.
Step five, make the decision, is now apparent by evaluating your pro and con worksheet. One would assume the option with the most pros would be the correct decision, but carefully evaluating the degree of severity regarding the consequences in the con column may have an affect on your decision.
In step six, you are now ready to implement the decision. There is no sense in going through these six steps unless you’re serious about implementing the decision to your ethical dilemma. Without following through and acting on your decision to the ethical dilemma, there will be no resolution for the patient or party affected.
Knowing the major principles of health-care ethics and how to use a model to solve an ethical conflict is the best way to solve a dilemma. Weighing all outcomes is necessary to reach a fair resolution for each party. Working through an ethical dilemma does not come easily, but takes practice and careful consideration. This is why educational ethics programs in dental hygiene schools are important. When instituted within the curriculum, hygienists have the opportunity to participate in group instruction and use workshops to role-play. Through this, dental hygiene students see “how experienced ethicists reason through problems,” and there are “right answers to ethical problems and that it is not just a ‘matter of opinion.’”9
To date, there appears to be no gold standard in teaching ethics to dental hygiene students. However, allowing students a personal experience via instruction and role-playing engages students in realistic ethical discernment, which gives them the “tools necessary to deconstruct an ethical dilemma.”4 Continuing and broadening school-setting ethical training instruction is necessary to increase hygienists’ awareness in solving ethical conflicts. Then hygienists can address, analyze, and solve ethical dilemmas properly using their ethical training within the “context of clinical, workplace, and professional situation[s].”4 RDH
Marcy Ortiz, RDH, BA, is a practicing dental hygienist for 25 years, the last 16 years in a geriatric dental practice in Sun City West, Ariz. She is a 2010 Arizona State University alumna graduating summa cum laude and a member of the Golden Key International Honour Society. She is the current vice president of education for Camelback Toastmasters in Glendale, Ariz. and recently awarded 2010-11 Outstanding Area Y7 Toastmaster of the year. Marcy can be contacted at Ortiz7688@cox.net.
1. Beemsterboer P. (2010). Ethics and law in dental hygiene (2nd Ed.). St Louis, MO: Saunders Elsevier.
2. Ethics Definition. Retrieved Dec. 27, 2011 from http://www.merriam-webster.com/dictionary/ethic
3. Shaw DD. (2009) Ethics, professionalism and fitness to practice: three concepts, not one. British Dental Journal. 207(2), 59-62.
4. Brondani MA, Rossoff LP. (Nov. 2010). The “hot seat” experience: a multifaceted approach to the teaching of ethics in a dental curriculum. J Am Dent Educ., 74(11):1120-1229.
5. Brennan M. (March 2010). Why bother with ethics and law? Vital [serial online] 7(2): 37-39. Retrieved from: Academic Search Complete, Ipswich, Ma Accessed December 28, 2011.
6. Hamel O et al. (2006). Ethical reflection in dentistry: first steps at the faculty of dental surgery of Toulouse. J Am Coll Dent., 73(3): 36-39.
7. Wentworth R. (Sept. 2010). Ethical moment: what ethical issues should general dentists consider when the state of the economy affects decisions regarding referral of patients to specialists. J Am Dental Assoc., 141 (9) p. 1125-1126. Retreived online Dec. 9, 2011 from http://jada.ada.org/content/141/9/1125.full
8. Wentworth R. (June 2010). Ethical moment: what ethical responsibilities do I have with regard to radiographs for my patient? J Am Dental Assoc. 141 (10): 718-720. Retreived Dec. 9, 2011 from http://jada.info/content/141/6/718.full?related-urls=yes&legid=jada;141/6/718
9. Jenson L. (February 2005). Why our ethics curricula do work. J Dent Educ., 69(2):225-8.
Four principles of health-care ethics1,4,5
- Includes “Self-determination, the right to decide what happens or does not happen to us”5
- Knowledge of all information regarding treatment, risk, and benefits
- Patients make their own decisions, the right to say yes or no to treatment
- Patients have a right to confidentiality and privacy regarding their health care
- Promote good for the patient; protect the patient from harm
- Acting in the best interest of the patient
- Do no harm
- Do not undertake a procedure without the patient’s consent (informed consent) or do a procedure for which you are not adequately trained
- Be fair and treat patients equally
- Do not discriminate any patient seeking a dental diagnosis or treatment
Past RDH Issues