The attractive elderly woman on the glossy front cover of the brochure had an appearance that revealed the expected attributes of aging. Sagging jowls and wrinkles appear on a face framed by a shock of white hair. Her mouth formed a whimsical “o” hiding teeth, which is likely an intended feature of this ad for cosmetic dental services. The viewer is left to imagine that were she to smile, this vibrant octogenarian would display cosmetically enhanced teeth – teeth that are white, ordered and esthetically designed to give her a younger, more attractive appearance. Although such ads are meant to promote cosmetic dental procedures, they also illuminate the commercial side of contemporary cosmetic dentistry. What values guide dental practitioners who provide cosmetic enhancements- the pursuit of beneficence, beauty or “bucks” (financial reward)? In general how do cosmetic procedures influence the way we define what is normal and healthy? This discussion is intended to highlight areas of ethical concern about cosmetic dentistry while examining how addressing these areas of concern is a responsibility not only of the individual practitioner, but also of the organizations that represent dentistry as a health care profession.
Ethics is a generic term used “for various ways of understanding and examining the moral life.1 In healthcare ethical considerations centre on the values that are intrinsic to the act of caring for others. Obligations like beneficence, promotion of autonomy and truthfulness reflect the underlying ethical nature of the dentist-patient relationship. Professional associations develop codes of ethics that outline to stakeholders the duties intrinsic to the role of healthcare professionals. The professional obligations contained in such codes address the social contract that exists between the health discipline and the society in which health practitioners are trained and licensed.2 Dentistry has historically been a healthcare profession with core ethical obligations that centre on the duty to treat and prevent disease and ultimately to promote patient well-being.3
For the purpose of this discussion the term cosmetic procedures refers to essentially elective procedures performed on normal tissue in order to enhance appearance while maintaining functional integrity. As one author stated cosmetic procedures are often intended to make patients “better than well”.4
A prevailing concern about cosmetic dental procedures is a lack of clarity between providing a good restorative treatment with a favourable esthetic outcome and cosmetic procedures that could constitute overtreatment.3,5 Dental practices not only provide essential health services, they are also profit-oriented businesses. These factors can constitute an inherent ethical tension for dentists who offer cosmetic procedures to their patients, the fees from which result in considerable profit. Cosmetic procedures are lucrative-bottom line.6 At the same time these cosmetic procedures are frequently requested by patients themselves. Cosmetic dental procedures involve technical skill and clinical knowledge that only a trained and licensed dentist can provide. In practice, the dentist ostensibly wears two hats — one as a health professional and another as a businessmanager/owner. But any associated ethical tension this may raise does not necessarily mean that offering cosmetic procedures to patients is unethical. As a health care professional, a dentist is obligated to address such challenges with ethical discernment in order to avoid harms that could result such as over-treatment. Of central concern is whether the procedures offered meet with primary professional obligations to protect and promote health and well-being of the patient. The “commerce of dentistry” must always remain a secondary consideration for the dentist proposing cosmetic procedures.3
The matter of autonomy vs. beneficence and non-maleficence can also raise interesting ethical tensions for a dentist. An elderly patient with several chronic medical conditions for example, may request cosmetic procedures that include implants and cosmetic enhancements for existing teeth. In such cases where the health profile of the patient may seriously increase the risk of complications, the principle of autonomy does not supersede the duties to first do no harm (beneficence) and to avoid unnecessary suffering (non-maleficence). Cosmetic procedures like all dental interventions may come with risks, and risks are unfortunately realized by some patients. The dentist whose elderly patient makes such a request is duty bound to offer only those procedures (restorative or cosmetic) based on reasons that are clinically advisable and ethically defensible. Key to preserving autonomy is ensuring that patient consent is informed and voluntary. A truly informed decision regarding cosmetic dental procedures must include information about benefits as well as risks both in the short term, and in the long term health picture. This information is particularly important as the long-term risks and benefits may be different from short-term when normal tissue is to be replaced with foreign materials for cosmetic enhancement.
Some authors warn against allowing cosmetic dentistry to become a specialty. Authors like Simonsen 3 argue that “the marketing and selling of “cosmetic” dentistry” challenges the traditional view of dentistry as a health profession in which the esthetic aspect of treatment is only one indicator of good health outcome. Mulcahy5 warns that there is a “decline in concern for ethical judgment in the basic principles of practice management” and worries that if a specialty of cosmetic dentistry were to emerge, then dentists may evolve from being “doctors to mere clinical technicians”. There is also a call in both medicine and dentistry for increased regulation and clarity in standards for training health care professionals who provide cosmetic procedures.3,7,8 In a statement released by the Quebec College of Physicians calling for new regulations for doctors who are profiting from cosmetic procedures, current cosmetic medicine in Quebec was referred to as the “Wild Wild West”.8 Perhaps it is time for professional organizations that regulate dentistry to examine whether existing standards and regulations are sufficient to prevent the “Wild Wild West” phenomenon in the area of cosmetic procedures in dental practices.
However, in the opinion of this author what is not discussed sufficiently concerns the broader social impact of market-driven standards for beauty that have infiltrated respected health care professions like medicine and dentistry. These “healing” professions have entered an ethically complex arena of selling beauty enhancements to patients who can afford them. Standards of beauty reflected in the sea of images we are exposed to on a daily basis like the “Hollywood” smile and Botox injected frozen faces have confused broader notions of what is to be considered normal and healthy.6,9 The popularity of teeth whitening procedures illustrates how market-driven advertising has influenced how we perceive health, beauty and well-being. One study linked the increase of patient requests for teeth whitening procedures to popular media campaigns to promote these products and procedures.10 But do such standards for beauty best serve the duties of health promotion, disease prevention which are the hallmarks of dentistry? When considering the well-being of patients, one cannot ignore the social, economic and emotional rewards that patients feel they will derive from looking better or more youthful.11 As stated previously, esthetics in restorative dentistry has always been considered when determining a good outcome. According to one author, dentistry as a profession is dedicated to “perfection” with cos
metic aspects central to the care provided.5 Dentists must discern when they reach an ethical “tipping point” in the treatment of their patients. This is a point at which the obligation to preserve and promote health could be compromised by the pursuit of esthetic or cosmetic perfectionism.
This tension between the ideals of dentistry as a healing profession and the commercialization of cosmetic dental practice requires some critical thought with appropriate guidelines developed by both individual dentists and their representative organizations. Educational efforts can increase ethics knowledge and capacity and can help prevent dentistry from losing its focus on preserving and promoting oral health as a primary ethical obligation. Case examples of patients and cosmetic procedures with commentary that includes ethical considerations as well as matters of clinical management should be readily available to dentists through their college or association websites. Continuing education in the area of cosmetic dental techniques should include discussion about ethics, health promotion and the influence of market-driven standards of beauty on patient’s perceptions of oral health and appearance. According to Schwartz12 dentists must receive adequate ethics education to be reflective practitioners, that ethical reflection in daily practice is “a pillar of dental professionalism”. Dental associations and colleges are encouraged to assess the current levels of ethics education in dental programs to determine if they are adequate to help graduates address the ethical challenges they will face with regards to cosmetic procedures.
Professional ideals focused on the most fundamental obligations of preserving and promoting oral health define dentistry as a healthcare profession within this broader societal context where artificial and market-driven standards of beauty are being confused with notions of health and well-being. Conscientious effort by both individual dentists and their representative organizations is needed to ensure that ethics remains at the heart of current dental practice and will continue to guide standards and treatment options in the future.
The author wishes to express deep appreciation to Dr. Rollin Matsui for his contribution of time, expertise and advice in the writing of this article.
Karen Faith is a bioethics consultant and former Director of the Ethics Centre at Sunnybrook Health Science Centre in Toronto. She is an adjunct lecturer at the Factor-Inwentash Faculty of Social Work at University of Toronto, an Organizing Board Member of the Clinical Ethics Summer Institute as well as a member of the Joint Centre for Bioethics. Karen has presented locally, nationally and internationally on topics pertaining to ethics in healthcare. She has a particular interest in organizational ethics, values centered leadership as well as women’s health. She can be reached at email@example.com.
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