applied ethics in dental practice · 2019. 6. 5. · ethics, professionalism and ethical...

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Applied Ethics in Dental Practice

Barry Schwartz DDS, MHSc (bioethics), cert ADR, FPFA, FACD

Assistant Professor, Schulich Medicine & Dentistry, Western University, London Ontario

Mar 2, 2018

Purpose of todays talk and discussion

To better understand and apply dental ethics and decision-making in common practice situations

This afternoon session will provide some context to ethical decision-making and discuss some cases to highlight the ethical principles and professional values involved

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What is meant by ethics?

The moral principles or virtues that govern the character and conduct of an individual or group

It is a branch of philosophy that seeks to identify what is good and to help answer 2 important questions:

1. What should we do?2. Why should we do it?

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What Ethical Issues Challenge Dentists ( a short list)

Informed consent Privacy/confidentiality Conflicts of interest Access to Care Child Neglect/Abuse Cultural relativism Professional

boundaries Emergency care

Disclosure/ misrepresentation

Incapacity of dentist or patient

Managed care (capitation, preferred providers)

Referrals Patient abandonment Sexual harassment

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A Principle-Based Approach-Beauchamp & Childress

1. Respect for Autonomy- allowing patients to choose what is in their best interest

2. Non-maleficence- avoiding harm to the patient (and others)

3. Beneficence- helping others4. Justice- following the laws, fair

distribution of burdens and benefits7March 2, 2018 barry.schwartz@schulich.uwo.ca

An Ethics Analogy

Give a hungry man a fish and he will be satisfied for a day.

Teach a man to fish and you have fed him for a lifetime.

‐Lao Tzu

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Core Values of Professionals1. Integrity: telling the truth (Veracity), keeping

promises and not breaking confidentiality (Fidelity), upholding professional principles (of beneficence, justice, non-maleficence and autonomy---previous slide)

2. Compassion: acting with sympathy and kindness to all patients in alleviating their concerns and pain

3. Competence: acquire and maintain the necessary expertise to undertake professional tasks (life-long learning)

4. Being Reflective: 10March 2, 2018 barry.schwartz@schulich.uwo.ca

The ACD Test For Ethical Decisions (American College of Dentists)

AssessIs it true?Is it accurate?Is it fair?Is it quality?Is it legal?

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The ACD TestFor Ethical Decisions

Communicate Have you listened? Have you informed the

patient? Have you explained outcomes? Have you presented

alternatives?

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The ACD TestFor Ethical Decisions

Decide Is now the best time? Is it within your ability? Is it in the best interests

of the patient? Is it what you would want

for yourself or a member of your family?

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A Decision-Making Model (Ozar & Sokol)

IdentifyAlternatives

Determine what is professionally

at stake

Determine what is ethically at

stake

Rank the successful

alternatives

Choose a course of action

What ethical considerations apply to the considered actions?

What guidance does the RCDSO code of ethics

provide?

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What if we don’t make good ethical decisions?

Our reputation suffers! Our profession is demeaned! Our patients lose trust in dentists! It can have an impact on our self-

esteem and mental/physical health!

It can create unhappiness with our staff

It can impact on the bottom line! 15March 2, 2018 barry.schwartz@schulich.uwo.ca

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How do we manage conflicting values?

We must rank our values depending on the likely consequences of our actions

Prima Facie Duties- not rules but guidelines to uphold central values

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Ranking of Central Values in Dentistry (Prima Facie= order that is presumed to be true

unless disproved - not absolute)

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1. The life and well being of the patient2. Preservation of oral health and freedom of pain3. The patient’s autonomy- their expressed wishes

and needs4. Dentist’s preferred practice values: i.e. rubber

dam5. Aesthetic values: composite resins vs. amalgam?6. Efficient use of resources: cost to both the patient

and dentist7. Social justice: what do we provide for indigent

who can not afford the necessary treatment?

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Writing Off the Co-Pay

Dr. A works in a blue collar area where many patients struggle to get by. The auto plant, where most of the patients work, pays 80% of the current fee guide. In order to help out his patients, Dr. A routinely writes off the co-pay.

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Ethics Case 1: The Limits of Confidentiality

A longstanding patient asks to speak with you privately in your office. He tells you that he is positive to HIV/AIDS and trusts that you will keep this completely confidential. He is afraid that if other office members are informed, they will treat him differently and be uncomfortable with him. You have recently referred him for the removal of his third molars to an Oral Surgeon and he specifically told you not to tell him about this condition. He will decide if and when to tell anyone else. Do you maintain the confidence that has been entrusted to you, or do you secretly discuss the situation with your staff and/or the Oral Surgeon.

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Questions to consider:1. What options do you have?2. What ethical/professional values are involved in

this case?3. What plausible outcomes do you see?4. What specific guidance does the licensing body

and the code of ethics provide? 5. What are the repercussions for the

profession, the patient, and the public?6. What would you, as the dentist, choose to do?

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Case 1: A Recent Grad Reports…Recently I saw a 7 year old male patient on an emergency basis who attended an appointment with his mother. The patient presented with a dental abscess and mild facial cellulitis on the left side of his face. Looking over the chart, this patient had been diagnosed with 7 carious lesions 1 year ago, and the mother had kept cancelling appointments and not calling back after messages were left on her voicemail to book appointments (The mother also had a history of previously diagnosed caries that she did not seek treatment for, as well as an abscess that she received antibiotics for but did not show up to her appointment for final treatment). 34March 2, 2018 barry.schwartz@schulich.uwo.ca

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When these caries were again mentioned to the mother, she reacted as though she had no responsibility in the matter and blamed everything on the child. I emphasized that she needed to be helping him take care of his teeth. After conveying the diagnosis, I elected to refer the child to a dental anaesthesiologist due to poor patient behaviour and the number of lesions that required treatment. I prescribed antibiotics and informed the mother that this was a serious infection and she needed to call the anaesthesiologist office immediately to book an appointment, as there is usually a wait to get in to see them. We then informed the anaesthesiologist of the situation and they were waiting for the mother's phone call. One full week went by, and I followed up with the anaesthesiologists office to ensure that an appointment had been made. The office had not yet heard from the mother.

What would be your next steps and why?35March 2, 2018 barry.schwartz@schulich.uwo.ca

All in the Family by Barry Schwartz

Gillian is a recent graduate of dental school and her Mom, Clarice, is one of her first patients in private practice. Clarice has a cracked tooth that her last dentist was going to extract but Gillian thinks the tooth can be salvaged with some heroic measures such as a tooth lengthening procedure. Clarice fills out the medical history form but omits, under medications on the form, the Symbicort (a steroid bronchiodilator) which she takes for bronchiectasis (a COPD) because she does not wish her daughter to worry about this serious lung condition. Mom is nervous about her restoration appointment and Gillian, who has recently completed her nitrous-oxide program, suggests that they use nitrous oxide. Gillian reviews her mom’s medical history, which according to the sheet, was non-contributory and ensures that Clarice has not eaten anything in the last 2 hours. During the appointment, Clarice suffers respiratory distress and Gillian freaks out and starts crying as her mother begins to turn blue, after all- -this is her mother in the chair!

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Conclusions

Ethical conduct is directly related to patient trust

Utilizing a decision-making model can lead to better decisions

More ethical decisions are good for the dentist, the staff, the patients and the financial health of the practice

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References1. RCDSO Code of Ethics Nov. 2004

http://www.rcdso.org/KnowledgeCentre/RCDSOLibrary

2. Ozar/Sokol- Dental Ethics at Chairside. Professional Principles and Practical Applications. 2nd

Edition 20073. Principles of Biomedical Ethics.

Beauchamp & Childress 5th Edition 2001 49barry.schwartz@schulich.uwo.caMarch 2, 2018

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References (cont.)4. Ethics Handbook for Dentists. An Introduction to Ethics, Professionalism and Ethical Decision-Making. American College of Dentists. Revised 20165. The ACD Test for Ethical Decisions. American College of Dentists. (2015)6. Schwartz, B. Ontario Dentist. June 2003; The HIV-Positive Patient: The Limits of Confidentiality7. RCDSO Practice Advisory. Prevention of Sexual Abuse and boundary Violations. (Nov. 2015)

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