A committees morals

Dec. 1, 1999
Ethical dilemmas can occur in the office between clients and various members of the dental team. Employing a "cooperative" approach - enabling all team members to participate - to the topic of dental ethics offers considerable advantages for addressing moral, ethical, and legal issues.

Dental offices prepare for ethical dilemmas through the formation of an office committee.

Donna F. Homenko, RDH, PhD

Ethical dilemmas can occur in the office between clients and various members of the dental team. Employing a "cooperative" approach - enabling all team members to participate - to the topic of dental ethics offers considerable advantages for addressing moral, ethical, and legal issues.

In a hospital setting, it is not uncommon to find an ethical advisory group known as an Institutional Ethics Committee (IEC). This group fosters the self-education of its members and a systematic application of a variety of decision-making models. An IEC emphasizes the ethical implications of clinical care. For example, recommendations may be made about "do-not-resuscitate" (DNR) orders and available organs for transplant.

Ethics committees in dental offices could be established to address appropriate concerns and accomplish the primary outcome of interacting as a team on "difficult" issues or dilemmas. The agenda for a routine staff meeting could be dedicated to ethical issues or dilemmas on a periodic basis (perhaps during monthly or quarterly meetings). A Dental Ethics Committee (DEC) can become responsive to a variety of issues that occur in the oral care environment.

The ethical concerns in dental hygiene may not be the dramatic end-of-life issues portrayed on medical television shows. However, real-life scenarios involve confidentiality, infection control, quality assurance, fair treatment, treatment planning, and client documentation.

Through cooperative education strategies, the necessary communication among team members can be initiated. The World Council of Cooperative Education defines cooperative methodologies as "experiential learning in which groups improve their ability for decision-making and partnerships." Incorporating a "learning by doing" model is a format most team members experience throughout their professional careers. New products, modifications in client policies, and computerized management systems often are mastered by a trial and error methodology.

The dental ethics committee

The guidelines for a DEC must be presented to each staff member in the office. This process can begin by reviewing a recent problem that occurred in the practice. Dental personnel, for example, may have discussed a client`s personal and economic status, and other clients in the reception area overheard the conversation.

The main component of cooperative strategies involves awareness that all participants have an equal voice in the discussion. Titles and authoritative demeanors should be left "at the door." Secondly, no one person should dominate the discussion, including the dentist. All participants should address each issue or question as evidence of their commitment to understanding and resolving the issue. The conversation enables the team to openly and honestly express their views, attitudes, and beliefs. A single correct answer may not exist.

The DEC can then establish a self-educational structure similar to hospital ethics groups. Understanding what constitutes a dental health care professional can begin the process, utilizing a brainstorming format. Ethical topics to reflect on include the:

- Expectations of the public when dealing with a certified or licensed dental professional.

- Key factors that separate a committed dental professional from someone who just "does his or her job."

- Factors that apply to the role of each team member as he or she provides dental care to clients.

Ideas offered by the DEC acknowledge the extensive training required of dental professionals, specific information pertaining to the profession, and/or a sense of service to the community. A state`s dental practice act, the ADHA, or ADA Code of Ethics also may be referenced. The basic components of the ADHA code are applicable across dental disciplines and can serve to identify ethical terms or as a checklist of office protocol.

The following scenario is an example of how issues involving professionalism can be discussed. This is your first position in a large group practice that has three general dentists, a periodontist, and an orthodontist. The staff totals 14 members and includes chairside assistants, an office manager, roving infection control assistant, and two dental hygienists. Each day, a new staff configuration surrounds you, due to the large number of personnel who rotate between operatories or are part-time employees.

As a hygienist, your duties are quite varied, and the office manager encourages independence among the staff. On your way to find the supervising general dentist to check a patient, you notice one of the dental assistants scaling a child`s teeth in the next operatory. You question the dentist who seems to be unaware of the situation and suggests you discuss it with the office manager. At the end of the day, the office manager leaves early, but you encounter the chairside assistant who was performing the scaling. She is in the dental lab area where several other office employees are present.

Should the dental hygienist discuss the matter with the assistant the same day or wait until the office manager returns? What information should be documented?

In general, any formal code of ethics encompasses various degrees of ethical principles and theories. These basic principles apply to almost every aspect of a professional`s duties. In regards to the above scenario, respecting a person - including a colleague and doing what is best for the practice by identifying services performed outside the legal boundaries - embraces these ethical principles.

Assessing one`s personal moral beliefs can be accomplished by responding to the following questions:

- When do you first remember learning the meaning of right and wrong? Describe an incident or briefly explain the situation.

- Which individual(s) have been a role model in your life and why?

- Explain any rules that taught you to be a "morally good" adult in society?

- Which character traits are important to provide patient care and/or be a member of a health care team?

- Describe what you value most in life.

Responses to the questions may be written or verbalized during a DEC meeting. Team members` answers may vary. This exercise begins a clarification of the background and experiences that affect our abilities and decisions in the professional environment. Discussion should be open and individual differences should be respected. However, similarities in responses also may become apparent. In either scenario, the benefits derived from such an activity should focus primarily on becoming more cognizant of one`s feelings relative to morality in the dental practice.

The DEC should develop a sampling of ethical issues to address. These issues may be compiled from selected readings of articles in dental journals or by conducting an informal survey of activities that transpire between clients and co-workers. For example, how are clients greeted? Are treatment protocols consistent for each person? If not, what causes the variation in procedure?

Ask each dental professional to record (annotate) their conversations with clients and other staff members in the office for one day. Special attention should be given to those situations that caused a problem, resulted in negative feelings, or were not resolved. Each DEC member can anonymously select a different day within a two-week period to record observations. All notes should be objectively stated, devoid of extremes in emotion or opinion.

The DEC can then review the observations. Experts stress the importance of becoming more aware of ethical issues to enhance the sensitivity of practitioners and their ability to reason morally and critically when dilemmas arise.

Applying ethics in the oral care environment

Specifically, ethics is a branch of philosophy that examines moral reasoning employed by an individual or group. In the dental profession, ethics focuses on moral duties and obligations to clients, co-workers, and society based on acceptable standards of care.

A case-oriented strategy for the DEC might commence with an examination of the informed consent document signed by clients. Recognizing that informed consent is an ongoing process and not only a form to sign, a checklist for office protocol must include the nature and purpose of the proposed treatment; risks and benefits; who will be rendering the care; and alternatives (if any) that exist if no further care is obtained.

If a combination of verbal and written consent is not currently the routine, then consideration for developing a case-consultation appointment - as well as the documentation provided by comprehensive progress notes - may be needed to comply with legal guidelines of the state practice act and ADA Risk Management recommendations. Documentation of the informed consent process mandates consistency and a detailed account of the treatment protocol.

The ethical concept of beneficence implies "doing good" for the client. In conjunction with another basic principle, non-maleficence (to do no harm), the dental team should strive to promote optimum oral health. The components of these two principles offers the dental health team a standard of care which promotes good and inflicts no harm. The concern of weighing the risks of harm against possible benefits challenges dental professionals. Occasionally, dentists and hygienists are accused of acting "paternalistically" on behalf of a client. Knowing what is best for the client and sharing sufficient treatment details could avoid discrepancies between the duties of the dental professional and the client`s rights.

The scenario described about "Charlie" on page 35 focuses on the principles of autonomy and beneficence.

Identify the ethical nature of the concerns expressed by Charlie`s mother related to the care he received. Consider issues regarding informed consent - services to be rendered and who would provide the care. Discuss an office protocol for treating minors in the office, especially when the family is not familiar with the philosophy of the practice. Finally, did the hygienist act beneficently toward the client? If so, what was the basis for the mother`s concern?

Infection control can be used to reference the principle of nonmaleficence. Although OSHA requires "universal precautions," variations exist in how dental offices interpret these guidelines. The DEC, referencing a state`s dental practice act, can assure appropriate disinfection and sterilization methods by developing a step-by-step list of all infection control activities. A large chart-size paper or spiral notebook placed in the dental laboratory area can serve as a recording site. Each member of the dental team should contribute to the list. Entries should be numbered separately. A follow-up session by the DEC can evaluate the office protocol for any voids in the aseptic chain. While this may not at first appear to be a major ethical issue, it is in fact a duty monitored by all dental boards.

Another principle, referred to as the "ethic of caring," converges on the principle of justice by describing the importance of maintaining relationships and a discerning responsibility to care for others in a variety of situations. Operating from a "feeling" of emotional reasoning, an ethic of caring has received considerable favor among feminist proponents in the disciplines of allied health and nursing. The basic premise integrates the goals of caring with fairness.

The principle of justice, according to one dental moralist, is synonymous with access to care and the obligation of the dental team to provide clients with equitable treatment, realizing the limited nature of health care resources. Applications of justice in the dental office relate to providing the same quality of care, regardless of clients` physical condition, such as HIV-positive clients or a client who belongs to an HMO.

When considering the principle of justice, the DEC begins by defining the standard of care clients should expect from the office. A clear and concise message of "just" dental care provided for all clients is desirable and should be communicated to any person treated in the practice.

An application of justice and its effects on the equitable allocation of resources when providing preventive procedures is illustrated in the case about "Sarah."

Is the hygienist justified in altering the types of services provided to Sarah and her family? Identify the ethical issues presented by the apparent guidelines used by the office to treat clients based on their method of reimbursement.

A discussion of confidentiality, role fidelity, and veracity includes the underlying theme of duty in the decision-making process.

Briefly, a definition of confidentiality involves the notion of information disclosure. The principle of confidentiality builds trust and ultimately enhances human dignity between the office and the clients who are treated. All data shared by the client, a relevant third party (parent or caregiver), or obtained through written documentation/electronic data is considered "sensitive" information accessible to those persons directly responsible for client care. While clients have a right to access their dental records, the actual documents are the property of the practice. Thus, all personnel have the duty to maintain confidentiality of the records. To evaluate confidentiality in the practice setting, a flow chart of how client information is handled in the office should be developed. Office policies stating the role and responsibilities of each dental professional to assure confidentiality can be developed during a DEC meeting. Particular attention needs to be focused on the potential for ethical dilemmas that arise when unauthorized personnel access computerized data/charts.

Role fidelity specifically addresses the relationship that exists between a dental practitioner and the client. Referred to as the "provider-patient" relationship, it is morally right to keep promises and other commitments when rendering dental care. It further supports a feeling of "faithfulness" toward clients` rights in all aspects of the treatment process. Role fidelity correlates with a professional`s duties and the principles of confidentiality and veracity.

Veracity, or truth-telling, is also linked to the concept of a dental professional`s duty to tell the truth. Some philosophers describe veracity as an ideal or absolute. We must always tell patients the truth or answer their questions honestly. To lie to a client is generally considered ethically unacceptable, making that person`s autonomy liable to deceit. According to statutory laws, as defined in a state`s dental practice act, the scope of services that can be performed by the various members of the dental team is explained. A client may ask the dental hygienist, for example, "So, how many cavities do I have?" The hygienist must respond within legal boundaries that do not permit diagnosis of decay, even though the conditions may be obvious. Although this example could be considered a lack of veracity, given current practice regulations, it would be more ethically correct to defer such questions to the licensed dentist.

The case describing the "Tenners" challenges the ethical principles of confidentiality, role fidelity, and veracity.

How should the hygienist respond to Mr. Tenner`s statement on HIV? Does the hygienist have a duty of confidentiality to these clients? Explain this role in lieu of the medical and personal information shared by the Tenners. Should the dental hygienist, as a health care professional, follow-up these office visits in any way to ensure fidelity and veracity have been demonstrated?

The DEC can discuss each of the ethical principles above as they pertain to specific cases. The conversation may be analyzed for reoccurring ideas or themes when reviewing what should be done in the situation presented.

A basic decision-making model can be employed using a "T-chart" or listing the advantages (pros) or disadvantages (cons) in reasoning through these dilemmas. In general, the critical concerns addressed by the DEC should revolve around the question, "Is the recommendation for action in this case morally defensible?"

For example, could the decision of the hygienist to tell the wife about the HIV status of her husband be defended to the client and to the employer, based on a Code of Ethics in a court of law, etc? Another way to evaluate a course of action would be to ask if it is possible to go "public" with the office`s decision. Would other dental colleagues agree with your choice? If not, then further scrutiny and reasoning may be necessary. It is not unusual for the DEC to ponder such issues without coming to a clear consensus of all team members. The salient points that are recorded by the committee, however, should assist the dentist, who has the ultimate legal responsibility, to make a decision.

The dental hygienist and supplemental dental team can work cooperatively to learn ethical content by initiating a DEC. The committee?s strategies start by developing a philosophy of professionalism in the practice setting. Ethical dilemmas that arise can be referenced in accordance with the ADHA/ADA Codes of Ethics and a state?s dental practice act. All dental health personnel should be familiar with ethical principles as they analyze their own actions and morality. The DEC?s activities facilitate the discussion of real-life scenarios in the areas of informed consent, treatment documentation, and patient rights. Aware of the many factors affecting dental treatment, the hygienist can serve to elevate ethical awareness in the practice setting.

Donna F. Homenko, RDH, PhD, is an associate professor in dental hygiene and health technologies-bioethics at Cuyahoga Community College in Cleveland Ohio. Dr. Homenko is involved with the instruction of professional ethics for dental hygiene and other allied health students.

References available upon request by e-mail at [email protected].

Taking care of Charlie ... without consent

Charlie is an eight-year-old boy who presents with a history of allergy to penicillin and a recent surgery for removal of his tonsils. The mother also comments on his fear of dentistry from previous negative experiences. Charlie`s family has just moved to your town, and he is the first of four children to be seen in the office. Upon a clinical examination, you notice rampant caries in the primary dentition and most of the permanent molars. Based on further questioning, you determine that Charlie and his family lived in a rural community and did not have access to city water.

As the appointment proceeds, Charlie begins to display signs of apprehension and refuses to cooperate with brushing and flossing instructions. When you go to the reception room to discuss the situation with the mother, she is gone. The front desk said she left abruptly after stating that she would return in about an hour. The client`s consent form has not been signed. You return to the hygiene operatory and proceed to expose radiographs, render a complete prophylaxis with fluoride and place a sealant on one permanent molar that was not decayed. When the mother returns, she is outraged that the dentist did not treat her son and refuses to pay for the "preventive" services completed by the hygienist.

Sarah`s ability to pay ... a lower standard of care?

Sarah has been receiving dental treatment in your office during the past five years. She is recently divorced with two school-aged children. Due to company layoffs, Sarah is not currently working and has applied for public assistance for the health care of her family. Previously, most of their dental services were covered by a private insurance plan.

Today, following the recare appointments for herself and the two children, Sarah expresses concern about the procedures that were completed and the amount of money owed. First, she questions why X-rays were not taken on the boys, ages 12 and 14. The receptionist indicates that, with public assistance, radiographs will only be reimbursed for one time per year. This confuses Sarah, since films previously were taken at each six-month recall interval due to a history of frequent decay. And, overall, she notices a decrease in the amount of time taken by the hygienist for her sons` cleaning, as well as the lack of no fluoride treatment.

The splitting of the Tenners ... no final comments?

As their dental hygienist, you have treated Mr. and Mrs. Tenner for many years, even before they were married. Both clients exhibit good daily home care and maintain a six-month recare interval. However, you notice today that their last visit was more than a year ago with several scheduled, but broken, appointments. Mr. Tenner is seen first and you notice a considerable decline in his periodontal health. He pauses and then confides in you he recently found out that he is HIV-positive, but asks you not to reveal this to the dentist. He adds that even his wife does not know about it.

Mrs. Tenner is seen next. She continues to display adequate oral health habits, but you question her about the chipped incisal edges on tooth #8 and #9. The client becomes very defensive and stutters with comments about falling on the ice last winter. You check her chart and notice these areas were not documented when she saw the doctor for an emergency visit two months ago.

During the appointment, Mrs. Tenner refers to her husband`s more frequent trips out-of-town, and how it is increasingly difficult for her to stay at home alone. Following their visit, you find out from the dental assistant in the office that the Tenners` have filed for a divorce and domestic violence is suspected.