November 1, 2001
by Dr. H. David Burstein
When first approached to write an article on dental ethics I was hesitant. Ask a specialist to discuss an aspect of their subspecialty and he/she could do it. But dental ethics? I am not an ethicist. I am not an academic. I am a wet gloved generalist. Besides being concerned of appearing sanctimonious, I would not want you to think that I do not struggle with ethical dilemmas in my own practice. However there are many issues and I was asked to help get a dialogue going.
Part of my interest in dental ethics stems from my belief that human nature is not inherently good. We are not inherently bad either. But just as good dentistry does not just happen, neither is decency between individuals. Therefore, we need guidelines to help us increase the possibility of ethical conduct.
Within dentistry, ethics can generally be divided into macro and micro arenas. The self-regulating nature of the profession is organized in a way to hopefully provide a fair and honest macro management of dentistry within itself and how it relates to society at large.
On a micro level, it is what goes on between our patients and our practices that is more important. What is ethical has to do with establishing an informed consentual relationship between adults. A foundation for this relationship should be based on the principles of: Compassion, Honesty, Integrity, Equality, and Fairness. CHIEF for short.
When we relate to our patients there is a difference in power. Patients come to us for our expertise. They are giving up a certain amount of control for the trust they put in us to provide them with a competent and safe service. The basis of ethics is not to abuse the power of the trust that our patients are giving us. We cannot use the power to steal anything from them. It is their health, time, money, decision making skills, integrity and dignity that must always be respected.
With the technological advances, information explosion, and increasing litigation in our society there is a greater need to include our patients in the treatment planning stages of work. Every person is different and there are usually many ways to treat cases. We are the experts, but it is their mouth. Increasing their involvement in the process is also part of building trust. When we do this there is less chance of there being any animosity if complications or even failure were to occur.
As the challenges of more comprehensive treatment planning mount their are some guidelines of what we have to do in explaining alternatives to our patients. Dr. Jeff Hoos has recommended the use of the B.R.A.N. formula. We must always present the: Benefits, Risks, Alternatives, and No treatment option.
In the book “Ethical Questions in Dentistry” by James T. Rule and Robert M. Veatch, published by Quintessence Books the subject of dental ethics is presented in a very thorough manner. The authors suggest that how we formulate our treatment planning and how we accurately evaluate our work also provides an ethical basis for our dentistry. They state:
“…most people tend to think of an evaluation as moral or ethical when it meets most, if not all of the following characteristics:
Ultimacy: that it meets the highest standard by which an action can be judged.
Universality: If other people are considering exactly the same action or character trait in exactly the same situation, they ought to come to the same evaluative conclusion.
Altruism or Neutralism: Judgments cannot be tailored to the advantage of the person making the judgment. Principles and rules of morality cannot be crafted to promote the advantage of the one stating them.
Publicity: One must be willing to state publicly the evaluation and the basis on which it is made.
Ordering: Any set of principles, rules, or character assessments should provide a basis for ranking conflicting claims. Ethical problems often arise in professional practice when one is caught between two competing obligations. For example, the dentist wants to do as much good as possible by restoring a certain tooth whereas the patient, appealing to autonomy, wants to have it extracted. A systematic ethical account should be able to tell which claim has moral priority and why.”
Once treatment options have been explained and the plan confirmed, cancellation policies and financial arrangements have been agreed upon, it is important that we have signed informed consent forms before starting with any work.
For all the legal necessities it is the human touch our of work that must never be forgotten. It is the golden rule of “Do not do unto others as you would not have others do unto you” that is the basis of ethics in dentistry. While new moral dilemmas always seem to be arising, if we start our approach to ethical matters from the perspective of how we would want to be treated if we were the patient, most of our interactions with our patients and staff can be handled in a just and agreeable manner. OH
“To me morality is the religious belief that some behaviour is right and acceptable and other behaviour is wrong. Since the crusades, the Spanish Inquisition and most recently the attack on the World Trade Centre, it is quite evident that any monotheistic religion can lead to fundamentalism and thus to a possible distortion of morality. As dentists, we must strive to maintain morality at its altruistic high–the imitation of God’s loving kindness. It is the pursuit of this intention that must drive our treatment planning and decision-making on a daily basis.”
Bruce Glazer, DDS, BScD
A clarifying question to ask in light of an ethical dilemma is: What would be the consequence if everyone acted in the manner under consideration?
“Good dentistry depends on one’s expertise and sense of fairness. Most dentists are good people if they have been adequately socialized. However, a small number of professionals tend to hurt and denigrate the profession. The major problem for the dentist is to consider himself inside the office and at home. The enactments of our own needs for money, power and dealing with disappointments can be projected into one’s work. Far too often the patient bears the brunt of one’s projected difficulties, interpersonally and in reality. One must remember that the patient has a dental problem that has to be dealt with humanely. Separately, we must look at ourselves in order that we can function with our patients based on the pleasure that we have in our work and the satisfaction in our personal lives. All of us will be very fortunate if we achieve this goal.”
Gerald Schneiderman, MD, FRCP (C)
“Successful dentists consistently demonstrate inate integrity. This characteristic is a cornerstone of having a rewarding career and life. Ethics means doing what is in the patient’s best interest, period. That should be the sole driving force.”
Janice Goodman, DDS
“While it seems intrinsically ethical, as Dr. Burstein paraphrases in his golden rule, not to “hate another in your heart” (Leviticus 19:17), the end of the verse contextualizes the height of this demand, namely, that “You shall surely rebuke your neighbour and not bear sin because of him.” Resistance of succumbing to what is hateful should be seen as only a beginning. If this beginning is held up as the ideal, then such a bare minimum of conduct can lead to a “gray” practice. The more noble ethical task to which we must all strive–the one which brings so much collegial conflict within the dental profession–is the moment that one specialist is called upon to rebuke another practitioner for, yes, actually having done that “hateful” work to a patient. How might the ethical task of peer review and its incumbent criticism be restored to its pristine ethical imperative? How can the dental community grow from this calling of “You shall not hate another in your heart” (Leviticus 19: 17), towards the task that ethicist Ehmanuel Levinas interprets in the very next verse of Leviticus 19 as: “Love your neighbour, this work is like yourself.” I submit that the work of any community, especially in dentistry, is the cultivation of humility that will allow for the receipt and acceptance of criticism towards rectification of faulty work as well as its prevention.”
Rabbi Aubrey L. Glazer, MA
Dental ethics is what you do in that little 10-foot square operatory when no one else is looking.
“Few clinical decisions are as difficult to make as knowing when not to operate, however, the ‘no treatment’ option does not guarantee the elimination of risk in all cases. Doubtless, good judgement comes from experience and experience comes from bad judgement.”
Simon Weinberg, DDS, FRCD(C)