A moral dilemma

April 1, 1998
Although laws define the obligations of health-care professionals, these obligations often extend beyond the scope of the law. The health-care provider has ethical obligations that, while they might encroach the boundaries of the law, cannot be legally enforced.

What happens when ethics textbooks tell us one thing, but our hearts react differently?

Mary Danusis Cooper, RDH, BS, and

William H. Bruening, PhD

Although laws define the obligations of health-care professionals, these obligations often extend beyond the scope of the law. The health-care provider has ethical obligations that, while they might encroach the boundaries of the law, cannot be legally enforced.

To help determine the ethical obligations health-care professionals should adhere to, the American Dental Hygienists` Association developed a professional code of ethics for hygienists. The Dental Hygiene Code of Ethics describes views on morals and ethics that should serve as a guide. As professionals, dental hygienists often have choices to make in response to issues and dilemmas within their practice settings.

The purpose of the Dental Hygiene Code of Ethics is for its members to achieve "high levels of ethical consciousness, decision-making and practice." Assuming that a hygienist has achieved these goals, what choice does she make when she is torn between two, mutually exclusive courses of action? When a hygienist knows that selecting either of two alternatives might have both good and bad consequences, the issue is which alternative should she choose? Such a situation is a classical example of a moral dilemma. A moral dilemma exists when "... an agent morally ought to adopt each of two (or more) alternatives separately, but cannot adopt both (or all) of them together."

A case study

The best way to illustrate a moral dilemma is to look at a specific example. Consider the following case: Carol Smith has been a dental hygienist for 10 years and works full time in a general-practice setting. Her best friend`s husband, Bob McComb, has been a patient of record for the past seven years. Upon updating his medical history at a recent visit, Bob stated that he was HIV-positive. After the initial shock, Carol asked Bob how long he had been aware of his current health status. He told her that he had just been diagnosed HIV-positive within the past month. He also informed the hygienist that his wife was not aware of his condition.

Carol wondered what she should do. Although Bob had informed her of his seroconversion, how could she not tell his wife? Carol recalled her most recent conversation with her best friend and remembered that she had shared that Bob had been acting withdrawn for the last few months. Perhaps, Carol thought, she should inform her best friend about her husband`s health status. However, she knew that her patient`s records were confidential. The relevant section from the American Dental Hygienists` Code of Ethics reads: "We respect the confidentiality of client information and relationships as a demonstration of the value of individual autonomy. We acknowledge our obligation to justify any violation of a confidence."

So what is Carol to do? If she tells Bob`s wife, she is violating patient confidentiality. If she does not tell Bob`s wife, she is placing her best friend at risk. Does her obligation to her patient outweigh her obligation to her friend? On what basis can she decide to override her patient`s confidentiality - an option her professional Code of Ethics allows, but does not specify how and under what circumstances it can be done.

Before Carol can solve her dilemma, she needs to ask herself the following questions:

- Does Bob`s wife have a right to know her husband`s HIV status?

- Is Carol the appropriate person to tell her?

- Does she have to act unilaterally? Can others help her?

- Should Carol involve the dentist she works for?

- Is the dentist required by law to report Bob`s HIV status?

Carol might even add other questions to her list. But more importantly, she needs to determine if the questions have a priority in being asked and hopefully answered.

The first question that needs addressing relates to Bob`s wife`s right to know his HIV status. If Carol answers this question negatively, then all of the other questions are moot and the dilemma disappears. From an ethical perspective, Bob`s wife has a right to know of her exposure to a person who is HIV positive. This is true for two reasons.

First, Bob`s right to privacy, and thus confidentiality of his dental records, is not absolute. A right is absolute if - and only if - any violation of that right is, by definition, unjustifiable. A right is fundamental if - and only if - any violation of the right needs to be justified. The professional Code of Ethics Carol is familiar with clearly presupposed that the right to confidentiality is fundamental, not absolute.

A second reason, not totally unrelated to the first, is that Bob`s right to privacy does not give him the right to cause harm to others who did not consent to that harm and who might even be unaware of its possibility. Thus, the hygienist might be in a "duty to warn" situation.

One of the most interesting examples of a "duty to warn" occurred in a California case in which a student killed another student. The killer informed professionals at the campus health-care center that he intended to kill the victim. These health-care professionals never warned the intended victim of the threat to her life.

The California Supreme Court, in its ruling, said: "We realize that the open and confidential character of psychotherapeutic dialogue encourages patients to express threats of violence, few of which are ever executed. Certainly, a therapist should not be encouraged routinely to reveal such threats; such disclosures could seriously disrupt the patient`s relationship with his therapist and with the person threatened. To the contrary, the therapist`s obligations to his patient require that he not disclose a confidence unless such disclosure is necessary to avert danger to others and, even then, that he do so discreetly and in a fashion that would preserve the privacy of his patient to the fullest extent possible, compatible with the prevention of the threatened danger."

Although the circumstances of the Tarasoff case are not identical to Carol`s situation, they are analogous enough to accept the point made by the state Supreme Court. Bob`s wife has a right to know of her exposure to an HIV-positive person.

The second question Carol needs to address concerns telling her best friend about Bob`s medical situation. Carol should not be the person who tells Bob`s wife. This is true for two reasons. First, Carol`s situation is complicated because she is dealing with her best friend. Carol might be having difficulty with the case because she is emotionally involved with Bob and his wife, not just as patients in the office, but also as friends. She has a conflict of interest that might cloud her judgment. She cannot, in this situation, be both a professional and a friend. In fact, even if she did not know Bob and his wife as friends, she still is not the correct person to inform her patient`s spouse. Secondly, other persons might be more appropriate to tell Bob`s wife. Carol needs to discuss the situation with the dentist. She clearly should not act unilaterally.

After a discussion with the dentist, the dentist should call the local Board of Health and/or a local AIDS task force for assistance. The local Board of Health should have a specific policy and procedure concerning partner notification. This policy would allow a third party to inform Bob?s wife, without identifying Bob, that she has been in contact with HIV. The local Board of Health would not identify who reported the contact. Some states do not require dentists to report cases of HIV, but they do require physicians to report such cases. Whatever the law is in your state, a call to the local Board of Health is appropriate.

Carol did not really have an ethical dilemma. She believed that she had an ethical dilemma because she knew her best friend had a right to know of her contact with an HIV-positive person. She also believed that she was the person who should tell her. When Carol realized that she was not the appropriate person to inform her friend, the dilemma disappeared.

Dental professionals should have a written policy and procedure that address confidentiality of patient records. Such a policy and procedure should be consistent with the laws of the state and with well-accepted norms of professional ethical conduct. Had Carol known of such a policy and procedure, she would have informed the dentist. Then, the dentist would have made a call to the appropriate agency, and the agency would have informed Carol?s friend.

Mary Danusis Cooper is associate professor of dental hygiene and Dr. William H. Bruening is professor of philosophy and director of the Center for Applied Ethics at Indiana University-Purdue University at Fort Wayne, Ind.


Y Becker, Lawrence C. and Charlotte B. (1992) Encyclopedia of Ethics, p. 836. New York: Garland Publishing, Inc.

Y Tarasoff vs. Regents of University of California, 551 P. 2d 334, 1976.

Y OThe Dental Hygiene Code of Ethics.O Access 1995; January: 9 (1): 51-57

Y Woodall, Irene R. (1987), Legal, Ethical, and Management Aspects of the Dental Care System, p. 54-55. St. Louis: C. V. Mosby Company.