Ethical Dilemmas in Dentistry, First Series

encompassing “Dr. Boley’s Dilemma”; “Let’s Pull It, Mom”; “Confidentiality of a Pregnant Adolescent.” (1 credit hour)

Learning Objectives

After completing the course, participants will be able to:

  • Understand the issues surrounding the ethical dilemma of reporting a colleague to the appropriate reviewing agency for providing inappropriate and/or incompetent care
  • Understand the issues surrounding the ethical dilemma of a child patient desiring a first molar extracted that could reasonably be retained and restored to health and function
  • Understand the issues surrounding the ethical dilemma of treating a 15-year old, pregnant and asked the dentist not to tell her mother
  • Understand the ethical reasoning behind the evaluation of these ethical dilemmas
  • Understand the decision making used to approach these ethical dilemmas
  • Understand options when confronted with an ethical dilemma

Please Review the Following Material:

Dr. Boley’s Dilemma

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Dilemma #2)

What Would You. Do?

Just over 3 years ago, Dr. Boley began practicing general dentistry in a community of 10 dentists. One of them, Dr. Leeds, has been in practice in the community for over 30 years and treats many of the older residents, who are very loyal to him as one of the “old-timers.” During one of Dr. Leeds’ infrequent absences, Ms. Wentworth, a longtime patient of Dr. Leeds, visited Dr. Boley for emergency treatment, which involved dental work recently completed by Dr. Leeds. Ms. Wentworth presented the sixth unsatisfactory case of Dr. Leeds’ work that Dr. Boley had observed during the past two years. In Ms. Wentworth’s case, an infected root tip had been left close to the sinus following an extraction and caused her considerable pain. After Dr. Boley recommended that the operation site be opened to remove the root tip, Ms. Wentworth questioned Dr. Boley about why Dr. Leeds had not removed the root tip at the time of the initial operation. She also asked about the quality of Dr. Leeds’ care in general.

It had been apparent to Dr. Boley for some time that Dr. Leeds had not kept up with the latest advances in dentistry and that both his technical ability and his clinical judgment were slipping. Ms. Wentworth, for example, suffered from advanced periodontal disease and needed replacement of almost all restorations. Ms. Wentworth reported to Dr. Boley, however, that Dr. Leeds had recently told her that she required no additional dental care. (Case cited from Weinstein, B. Dental Ethics. Lea & Febiger, 1993; p. 102. All names in the case are fictitious.) What would you do if you were Dr. Boley?

  1. Say or do nothing
  2. Discuss the problem with a colleague or friend
  3. Contact a member of the local peer review committee and discuss the case with him/her without mentioning the dentist
  4. Report the dentist to the local peer review committee
  5. Recommend that the patient review her case with a lawyer
  6. Contact a member of the Texas [Your] State Board of Dental Examiners and discuss the case with him/her without mentioning the dentist
  7. Recommend to the patient that she discuss the concerns with her previous dentist
  8. Other alternative. (please explain)
Response

In our second ethical dilemma, Dr. Boley is asked by Ms. Wentworth, an emergency patient, about the quality of care she has been receiving by her regular dentist, Dr. Leeds. Ms. Wentworth presented to Dr. Boley the sixth unsatisfactory case of Dr. Leeds’ work he had observed during the past two years. How should Dr. Boley respond to Ms. Wentworth?

Dr. Boley’s dilemma was no stranger to our readers as they related similar experiences and reflected on the perplexing nature of the problem. One reader “felt horrible” about the way he had handled a case, another felt “remiss for not dealing effectively” with another dentist, and a third wrote that reporting a colleague resulted in “hard feelings from this dentist’s buddies.” It was a “soul searching” experience for the readers. Dr. Boley’s dilemma is one of the most difficult for dentists because they must weigh the dual responsibilities of preventing harm to patients while preserving their own personal and professional integrity. Is Dr. Leeds’ work unsatisfactory? If so, what are Dr. Boley’s ethical obligations to report continually faulty work and what actions are available to her?

Levels of Adverse Outcomes

Dentists routinely assess the appropriateness and the quality of care provided by other dentists. When this assessment includes an adverse patient outcome, it is worthwhile to begin by defining issues of competency. The philosopher, Morreim1, identified five levels of adverse outcomes in order to separate ordinary mishaps from real mistakes indicating incompetence.

The first level of adverse outcome is the accident, an event totally out of the control of the dentist as what may result from an equipment failure. At the second level the dentist makes a well-justified decision that turns out badly, as in the case of a patient requiring antibiotic coverage, who has no known allergies to antibiotics, but suffers an anaphylactic reaction. The third level occurs when there are disagreements about treatment options, a common problem for dentistry.2 What are the options for the TMD patient, the patient with a malocclusion, or the patient who needs a three surface posterior restoration?3 There is as much uncertainty in dentistry as in medicine. The adage “ask three dentists for their advice on a case and you’ll get four opinions” applies. Simply because dentists disagree about treatment choices does not signify incompetence or mistreatment. The ADA Principles of Ethics recognizes this common occurrence when it states “a difference in opinion as to preferred treatment should not be communicated to the patient in a manner which would imply mistreatment.”4 At the fourth level, the dentist exercises poor, though not outrageously bad, judgment or skill. The general dentist may cement a full gold crown with a deep distal margin and determine that the margin is faulty at the next recall. The concern at this level is not the single error, but rather a pattern of errors as observed by Dr. Boley — a circumstance the ADA Principles of Ethics could describe as “continual” faulty treatment. At the fifth level are the outrageous violations such as the dentist who performs unnecessary treatment, performs surgery on the wrong site, or threatens the lives of patients5 — situations the ADA Principles of Ethics could describe as “gross” faulty treatment by another dentist.

Obligations to Report

The obligation to report a colleague suspected as being incompetent may be derived from several origins. When people are faced with ethical dilemmas they naturally fall in two primary categories6; those who guide their decisions by their principles (principlists} and focus on what is right; and those who set their principles aside and guide their decisions by stressing the consequences of their actions (consequentialists). The consequentialist focuses on that which produces the most good. For the principlist, principles such as “do no harm,” keeping promises, and the authority of codes of ethics may be the source of their obligation.

Physicians and dentists are instructed by the Hippocratic Oath to “above all or, at least, do no harm”, or simply phrased, “if you can’t help, at least don’t harm.” Dentists must routinely decide if a new product or technique is thoroughly researched, safe and effective, and when it is necessary to refer a patient who needs the skills of the specialist. Preventing the unnecessary harm of our patients is a key principle in health care ethics.

Keeping promises is another leading principle. The dentist enters the profession prepared to provide beneficial care and by staying contemporary in knowledge and proficiency, fulfills the promise to work in the patients’ best interest. We don’t expect this same treatment from a used car salesman where “buyer beware” may be the rule.

Official codes are another source of our obligations if we use their authority as our guide. The ADA Principles of Ethics4 states: “Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists.” The TDA Principles of Ethics7 goes further by stating: “Dentists should observe all laws, uphold the dignity and honor of the profession and accept its self-imposed discipline. They should report dentists deficient in character or competence or who engage in fraud or deception.”

For the consequentialist, the obligation to report depends on whether the individual is seeking the action that produces the greatest good for the greatest number or the greatest good for the individual. Dr. Boley is faced with alternatives that have overwhelming consequences. Although it could be argued that the greatest good would be served by reporting incompetent practitioners, thus preventing harm to patients, it is the decision of the individual to determine what is good for whom.

Actions for Dr. Boley

The action for Dr. Boley begins with a thorough review of the accuracy and fairness of her assessment of Dr. Leeds’ work. Were her concerns primarily a disagreement about therapy (level three), or a pattern of faulty treatment (level four)? We are not aware of the circumstances of the other five cases or if she is biased about his “old-timer” status. Emergency patients pose a special problem as our challenge is to manage the crisis — a situation that thwarts a thorough examination. Dr. Boley’s obligation to her colleague is to be fair and unbiased and to prevent an unnecessary harmful action. Her obligation demands that she perform a careful, thorough, investigation.

If Dr. Boley is now certain of the facts and circumstances surrounding the six cases she may decide to discuss the case, without mentioning Dr. Leeds, with a trusted colleague, a member of the local peer review committee, or an Examiner with the Texas State Board of Dental Examiners [or your Board]. These were choices selected by our readers. If after her discussions she decides further action is necessary, several options are available.

One reader recommended that Dr. Boley discuss the situation directly with Dr. Leeds, a reasonable action considering that patients sometimes misunderstand our explanations. Dr. Leeds may have informed Ms. Wentworth of the difficulty of the extraction and the need for periodontal and restorative care. This discussion may decide the need for further action by Dr. Boley.

Reporting Dr. Leeds to the local peer review committee was another option that readers selected in this case although it was presented in error, as “the current peer review system is not intended to handle a complaint initiated by one dentist against another.”8 Peer review was established to manage dentist to patient, and dentist to third party disagreements and was established by the ADA in 1970. As one reader stated, Ms. Wentworth “urgently needs to know the truth about her dental problems — it is morally and ethically imperative” and that Dr. Boley can communicate this and not “disparage”4 Dr. Leeds. In Texas, Dr. Boley could inform Ms. Wentworth that if she has a concern about the quality or appropriateness of her care she could call the local dental peer review committee. Peer review is available to both TDA members and nonmember dentists in Texas and in the calendar year 1991, Texas reported 534, or 13%, of the total of 4,030 peer review cases initiated nationally. Of the Texas cases, 60% were quality of care issues and 29% involved appropriateness of care issues.9,10

If Dr. Boley decides to file a complaint against Dr. Leeds she would contact the chairman of her local dental society committee on ethics and judicial affairs. If both dentists are members of the TDA the local committee would review the case. If one or both dentists are not members of the TDA the local committee would forward the complaint to the TDA’s Council on Ethics and judicial Affairs who would then forward the complaint to the Texas State Board of Dental Examiners for review.

There are several actions available to Dr. Boley and they are predicated on her careful and thorough investigation. None of the dentists responding to the case selected the option to say or do nothing, or to recommend that the patient review her case with a lawyer.

  1. Morrheim, EH. Am I my brother’s warden? Hastings Center Report, 23(3):19.27, May-June 1993.
  2. Bader, JD Sr Shugars, DA. Agreement among dentists’ recommendations for restorative treatment. Dent Res 72(5):891-896, May 1993.
  3. Sadowskv, D. Moral dilemmas of the multiple prescription in dentistry. J Am Coil Dent 46(4):245-248.
  4. ADA Principles of Ethics and Code of Professional Conduct. May 1992.
  5. McCarthy, FM. The Protopappas anesthesia deaths. JADA 110(1):26, Jan 1985.
  6. Matthews, M. Ethical reasoning: making ethical decisions in the context of dentistry. Texas Dent J. 32-37, Sept. 1992.
  7. Texas Dental Association Articles of Incorporation Constitution and Bylaws and Principles of Ethics and Code of Professional Conduct, p.18, Sept 1985.
  8. ADA Peer review in focus. Dentistry’s dispute resolution program, p.3 & 9, 1993.
  9. American Dental Association, Council on Dental Care Programs. National Peer Review Reporting System. 1992 Survey Results.
  10. American Dental Association, Council on Dental Care Programs. 1992 National Peer Review Reporting Calendar Year 1991 Data (Texas).
Conclusion

Dr. Boley’s ethical dilemma asks us to consider how we value our personal and professional responsibility to protect the health of the public and the integrity of our profession. A decision to report a colleague is one of the most agonizing dilemmas that dentists encounter and requires an extraordinary measure of wisdom, courage, and integrity. However, whether the dentist derives his or her decisions by principles or by consequences, since our duty first is to the patients’ welfare rather than our colleague’s career, evidence of manifest incompetence demands that we take steps to address it.

Editor’s Comment: Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry, the National Center for Policy Analysis or the Texas Dental Association.


“Let’s Pull it, Mom”

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Ethical Dilemma #3)

 What Would You Do?

Chad is a new patient in your general practice. He is fifteen years old, in good health, with only episodic dental care in the past even though his family has dental insurance. Chad presents with several small carious lesions, which is remarkable considering his high plaque index and (???) diet. During the summer, he rides with his father who drives a cookie truck and Chad admits to a heavy diet of cookies.

Besides the small carious lesions, there is a large occlusal lesion on #19 and a 2mm periapical radiolucency at the apex of the mesial root. There is a history of a painful episode “months” ago, but Chad is asymptomatic. Your diagnosis after clinical and radiographic evaluation is pulpal necrosis with chronic apical periodontitis. The prognosis for nonsurgical root canal therapy is good because of an uncomplicated canal anatomy and excellent restorability. Chad also presents with a seriously compromised occlusion. He has a Class II malocclusion with moderate-to-severe anterior open bite. Chad only contacts his molars in maximum intercuspation, so maintaining these teeth is important to his current function and for future orthodontic care. Your treatment recommendations include a thorough preventive program, including diet analysis, orthodontic evaluation, root canal and restorative therapy.

Chad and his mother are in your office for the consultation appointment. Both parents work and his father was unable to come to the consultation. You present your findings and Chad’s mother questions the necessity of root canal therapy, citing both the poor experiences of her friends and also the cost. You explain again the importance of this tooth, especially with Chad’s compromised occlusal function, but she seems unable to make a decision as to whether to allow root canal therapy for Chad. At this point, she turns to Chad and asks “what do you want, a root canal or would you rather have the tooth pulled?” Chad replies “let’s pull it mom.” His mother agrees.

Now you are faced with an ethical dilemma. What do you think you should do? Check the course of action you would follow.

  1. You decide to follow the desires of Chad and his mother and extract the tooth.
  2. You decide to follow the desires of Chad and his mother and extract the tooth after having her sign an informed consent for treatment.
  3. You again emphasize the importance of maintaining his tooth because of his compromised occlusal function but she insists that the tooth be extracted. You explain to her that you will not treat Chad but will see him for emergency care until she can find another dentist.
  4. You recommend that decisions as complicated as this one should be made by both parents and that you will be available to discuss the therapy with his father. You agree to provide treatment if both parents agree to either the root canal or the extraction.
  5. You offer to his mother the option to seek a second opinion from an orthodontist. Chad is evaluated by the orthodontist who agrees with maintaining #19. His mother insists that the tooth be extracted and you agree to extract the tooth after having her sign an informed consent for this treatment.
  6. You offer to his mother the option to seek a second opinion from an orthodontist. Chad is evaluated by the orthodontist who agrees with maintaining #19. His mother insists that the tooth be extracted and you explain to her that you will not treat Chad but will see him for emergency care until she can find another dentist.
  7. Other alternative (please explain).
Response

Your 15-year-old patient Chad (October issue) and his mother are discussing the treatment plan you have proposed, a plan that includes a thorough preventive program, orthodontic evaluation for Chad’s severe Class II malocclusion, a root canal for #19 and restorative therapy. You explained the importance of maintaining the molar, but Chad’s mother asks him “What do you want, a root canal or would you rather have the tooth pulled?” Chad’s reply is the title of this response.

What you, the dentist, decide to do for Chad should be weighed against a host of factors such as: should Chad have responsibility for making this decision, or should Chad’s father be included in the discussion? Is the decision based on the fear of the root canal treatment, or questions of cost (although they are insured)? Is it important to attempt to educate his mother again, or is the dentist’s primary duty to have the parent sign a consent to treat form? Do dentists have any special obligations to children, or should dentists always do what parents demand? And, will the decision be harmful to the patient?

Readers were split between those dentists who would extract and those dentists who refused to extract Chad’s molar. Those who would extract either discussed the case with Chad’s father (option #4), who consented to the treatment, or sent Chad to an orthodontist (option #5) and would extract in spite of the orthodontist’s recommendation to maintain the molar. Those who refused to extract sent Chad to an orthodontist (option #6) for a second opinion that affirmed that the molar should be maintained.

Respondents’ opposing views illustrate the difficult ethical issues in treating the child dental patient. An overview of informed and proxy consent, the question of harm, and paternalism may provide some perspective on the issues in this case.

Informed and Proxy Consent

Informed consent is based on the moral view that competent adults should have their autonomous requests respected; they have a right of self-determination because,1 as the patient, they are the expert in understanding their own values and priorities.2 Therefore, competent adult patients have the right to make decisions that affect their health, including the right to refuse life-saving procedures such as blood transfusions or to insist that you extract rather than restore a tooth, as in Chad’s case (though the health care professional also has the right to refuse the request).

What buffers decision-making in informed consent is the responsibility of the dentist to benefit the patient by not inflicting harm,3 by preventing and removing harm and by providing beneficial treatment.4 This conflict between respecting the autonomy of the patient while doing what is in the best interest of the patient is a common concern for health professionals. Informed consent seems to bring into conflict the issues: Is the dentist always obligated to do what the patient requests, or must the patient always do what the dentist recommends? Add to this dynamic predicament the ethical issues of proxy consent for children, and you broaden the margins of concern.

Proxy consent for children contrasts sharply with informed consent for adults because patients under the age of 18 have no autonomous rights of decision making other than those recognized by the state in special circumstances (e.g., marriage). Adults, usually the parents, are authorized to act for the child’s best interests. However, although a competent adult may refuse a life-saving blood transfusion, the courts have not allowed parents to make this same decision for children. Justice Rutledge put it this way: Parents may be free to become martyrs themselves. But it does not follow that they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make the choice for themselves.”5 Each state, for example, acting in its capacity of parens patriae — “has the sovereign right and duty to care for and protect the child from neglect, abuse, and fraud during minority.”6 This sovereign right to protect and care for children by overruling a parent’s objections is usually evoked in situations where imminent danger or the high risk of death to a child is possible, situations not common to dental practice. Consistent with the doctrine of parens patriae, dentists in Texas are designated as mandated reporters of suspected cases of child abuse and neglect and may be charged with a Class B Misdemeanor for failure to report suspected cases.7 In Texas, as in most states, dentists are granted immunity as mandated reporters.

Proxy consent intertwines the elements of the best interests of the child, First Amendment rights of the parents or guardians, the state’s capacity of parens patriae and the responsibility of dentists as mandated reporters. One issue central to understanding the case is the question of harm accompanying decisions to treat Chad.

A Question of Harm

Readers expressed opposing views regarding the possible harm for Chad resulting from the extraction. One dentist wrote: “When more than one good treatment choice is available, I think the patient’s wishes must be honored. However, I believe we should never become so compliant that we become accomplices in a harmful treatment choice.” Another dentist wrote: “It’s an imperfect world and Chad and his parents have been informed adequately of all the options. They just chose a bad option.” The dentists agreed that the root canal was the preferred treatment, although they were split between those that viewed extraction as an acceptable, or unacceptable, alternative.

Part of the difficulty in Chad’s case is assessing the amount of harm caused by extracting, rather than restoring, his tooth. The prognosis for maintaining the tooth with root canal and restorative treatment is good. Chad’s Class II malocclusion adds more weight to the decision to maintain the molar because his anterior open bite and molar occlusion support the need to maintain #19 for orthodontic treatment to establish appropriate function. The consultation with the orthodontist confirmed this assessment. Appropriate function is a key element in this case, as dentists are not required, and may ethically refuse, to provide care that would leave a patient with a significantly impaired or painful oral function.8

If an adult makes a decision that the dentist views is not in the best interest of the child, how can the dentist ethically justify refusing to provide the treatment?

Justifiable Paternalism

If a dentist imposes his or her views on a competent adult patient, the dentist is acting paternalistically — treating the patient in a fatherly manner as would a parent. However, proxy consent for children is a special circumstance because of the absence of the child’s legally recognized autonomy. Paternalism for children has been justified precisely for the purpose of “treating children in a ‘fatherly’ (and ‘motherly’) manner,” especially in situations involving the proper treatment of infants and very young children.9 In Chad’s case, the dentists who refused to extract the molar could argue that the refusal is an act of justifiable paternalism, and as one reader stated, “Refusal to remove the tooth in this case makes a strong ethical statement which might possibly cause the patient and his mother to change their minds.”

Conclusion

It is evident, from this brief overview, that treating the child dental patient, as opposed to an adult patient, places an increased weight of decision-making on the dentist. The child becomes by law, and perhaps by practice, silent. The dentist must decide how to manage the hosts of factors in each case — protecting the best interests of the child, the tension between beneficial and harmful therapeutic choices, the First Amendment rights of both parents and children — against their appropriate role as a health professional. When parents or guardians make poor or foolish decisions for their children that are harmful and thwart appropriate function, the dentist is ethically justified in refusing to render treatment.

References
  1. Canterbury v. Spence, 464F. 2d 772 (D.C. Cir 1972)
  2. Ozar, DT. Ethical issues in pediatric dentistry. Pediatr. Dent. 13(6): 374-376, 1991.
  3. ADA Principles of ethics and code of professional responsibility. Revised May, 1992.
  4. Beauchamp, TL. Principles of ethics. J. Dent. Ed. 49(4): 214-218, 1985.
  5. Prince v. Commonwealth, 321 US 158, 170, 64 SCt 438, 88 LEd 645 (1943).
  6. Morris WO. Ethical and legal duties of a parent to provide dental treatment to a minor. J. Law Eth. Dent. 1(4): 194-198, 1988.
  7. Texas Family Code. Chapters 34.01, 34.02 and 34.07. See also: ADA Council on Dental Practice. The dentist responsibility in identifying and reporting child abuse. 1989 Revision, p. 28.
  8. Ozar, DT, Schiederrnayeo DL, and Siegler, M. Value categories in clinical dental ethics. J. Am. Dent. Assoc. 116(3): 365-368, 1988.
  9. Gaylin, W, and Macklin, R. Who Speaks for the Child. New York, Plenum Press, pg. 295, 1982.

Editor’s Comment: Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry, the National Center for Policy Analysis or the Texas Dental Association. Address your comments to Dr. Thomas Hasegawa, Baylor College of Dentistry, P.O. Box 660677, Dallas 75266-0677.


Confidentiality for a Pregnant Adolescent

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Dilemma #5)

What Would You Do?

Mary Smith, a 15-year-old girl, came into a dental clinic for a recall appointment. She had been a patient of Dr. Virginia Jones for many years. While waiting in the clinic’s radiology area, she saw a sign instructing females to inform their dentist if they were pregnant. Mary became upset and asked Dr. Jones why the sign was there. Eventually she confessed that she was pregnant and asked Dr. Jones not to tell her mother.

Dr. Jones felt she had an obligation to inform the mother of Mary’s condition. Mary was not legally independent, and parents had to give consent for any treatment that Dr. Jones would propose. Because Dr. Jones knew Mary’s parents, Dr. Jones was convinced that it would be beneficial to Mary if her parents knew and could provide care and support during this difficult period for her life. (Courtesy of Rule, J. and Veatch, R. Ethical Questions in Dentistry, Quintessence Publishing Co., Inc., 1993, p. 143. All names in the case are fictitious; case printed with minor revisions).

Dr. Jones is now faced with an ethical dilemma. Check the course of action you would follow.

  1. Dr. Jones should try to convince Mary to discuss her pregnancy with her mother. Dr. Jones also should tell Mary that if she doesn’t inform her mother, she will.
  2. Dr. Jones should contact Mary’s mother and inform her that Mary is pregnant.
  3. Dr. Jones should try to convince Mary to discuss her pregnancy with her mother. Dr, Jones will not inform Mary’s mother and will try to delay dental treatment.
  4. Other alternative (please explain).
Response

Mary Smith (December issue) is a I5-year-old patient of Dr. Virginia Jones. Having come to the dental clinic for a recall appointment, she reads a sign in the radiology area that female patients are instructed to inform their dentist if they are pregnant. Mary becomes upset, asks Dr. Jones why the sign was there, and confesses that she is pregnant. She asks Dr. Jones not to tell her mother. Dr. Jones feels an obligation to inform Mary’s mother of her condition, as Mary is not legally independent and Dr. Jones is convinced that Mary’s parents would provide care and support.

What’s at stake in this case? Is Dr. Jones obligated to tell Mary’s parents that she is pregnant? When Mary confides this information to her dentist, should this confidence be respected? What moral obligations are required of dentists to respect the confidentiality of the doctor-patient relationship? Are there special considerations in this case because Mary is not legally independent?

The dentists that responded to the case selected two options, both beginning with “Dr. Jones should try to convince Mary to discuss her pregnancy with her mother and then, either “1. Dr. Jones also should tell Mary that if she doesn’t inform her mother she will,” or “3. Dr. Jones will not inform Mary’s mother and will try to delay dental treatment.” No one selected option “2. Dr. Jones should contact Mary’s mother and inform her that Mary is pregnant.”

Mary’s case illustrates the fact that dentists as health professionals are responsible for managing the personal information revealed by their patients. This moral responsibility is referred to as confidentiality, a core value in the doctor-patient relationship, and is cited in codes of ethics, based on trust, and may be broken in certain circumstances.

Codes and Confidentiality

Codes of ethics provide an insight into the central values of a profession. These codes may change and evolve, just as a dentist’s practice, patients and third-party interests change and evolve. Keeping the confidences of patients has been a core value in the AMA and ADA codes.

In medicine, the Hippocratic Oath has been a valuable source for describing professional obligations. The Oath advises physicians, regarding confidentiality, that, “whatsoever I shall hear in the course of my profession…if it be what should not be published abroad,. I will never divulge, holding such things to be holy secrets.” (1) References to confidentiality have been a part of the AMA Code from medicine’s first Code in 1847 to the current Code that specifies, “A physician shall respect the rights of patients, of colleagues and of other health professionals, and shall safeguard patient confidences within the constraints of the law.” (2)

In dentistry, although the first ADA Code of Ethics in 1866 did not mention confidentiality, the 1922 Code specified, “When a dentist is called in consultation by a fellow practitioner, he should hold the discussions in the consultation as confidential…” (3) The current ADA Code specifies: “Dentists are obliged to safeguard the confidentiality of patient records. Dentists shall maintain patient records in a manner consistent with the protection of the welfare of the patient.” (4) While the ADA limits confidentiality to consulting dentists and physicians, the Texas Dental Association’s Code of Ethics broadens third-party interests when it specifies: “Communications from and to patients are a matter of high moral significance. A dentist may not reveal the confidences entrusted in the course of professional treatment without patient approval unless required to do so by law or unless it becomes necessary in order to protect the welfare of the individual or of the community.” (5)

While confidentiality is a core value in the health professions as revealed in codes of ethics, the value of confidentiality underscores the necessity of trust in the relationship of patients and their doctors.

Trust

To understand the role that trust plays in a successful doctor-patient relationship, it must be viewed from the perspective of the dentist and the patient. From the dentist’s view, sound therapeutics begins with the patient’s trust because dentists ask patients to share personal and sensitive information necessary to properly assess their health and to determine proper therapeutics. Dentists are privy to information about serious health conditions, such as cancer and heart disease, conditions that may have profound social implications, such as HIV status and substance abuse, and sensitive personal experiences, such as child abuse and eating disorders. Without accurate and complete information openly communicated by the patient, the dentist’s care could harm rather than benefit the patient. Dentists also trust that the patient will keep appointments, fulfill financial obligations, and take responsibility for the maintenance of his or her own oral health.

From the patient’s view, the dentist is trusted to abide by the dental code of ethics. The ADA Code cites the benefit of the patient as the primary goal of the profession and calls upon the members to be caring and fair and to provide quality care in a competent and timely manner. (4) The patient shares personal and sensitive information with the confidence that the information will be used to promote the patient’s best interest and will not be divulged. The TDA Code asserts the respect for patients both in the commitment of the Code to the patient’s right to informed self-determination and by advising that dentists seek the patient’s approval before disclosure. The TDA Code also acknowledges that there are conditions that may require breaking confidences and specifies those instances. Mary Smith has asked Dr. Jones to keep information that has serious social and economic implications confidential. Confidentiality is a central means of assuring patients that their doctors will not misuse facts about their lives pertinent to understanding their illnesses. (6) Unlike the trust that must be earned, as in a friendship, the patient assumes a trusting relationship because of the dentist’s training and special role in society. (7)

To summarize, keeping confidences promotes trust and openness between doctors and patients and allows the patient autonomous control over personal or private information about themselves. Confidentiality affirms and protects the fundamental value of privacy and the social status of the patient, may be economically advantageous to the patient, and encourages patients to seek professional help when it is needed. (8) Breaking confidences, the central question in this case, must be justified considering these, as well as other, factors.

Breaking Confidences

Are there circumstances when breaking confidences is ethically justified?

The philosopher Campbell (9) identified five factors or conditions that may justify breaking confidences and they include: 1) does maintaining confidentiality place others at unknowing risk of harm, 2) will divulging information effectively protect others from harm, 3) is disclosure necessary to protect others from harm — is it the last resort, 4) if divulged, is it done in a manner with the least infringement, i.e., informing as few persons as possible, and 5) is the reason to breach confidentiality explained and justified to the patient?

In medicine, the philosopher Veatch (7) observes, “Twentieth-century ethics of organized physicians has supported breaking confidence in cases when there is a serious threat to third parties.” (7) In dentistry, these third parties include consulting physicians and dentists in the ADA Code and the individual as well as the community in the TDA Code. What are the risks of harm in this case?

There are potential harms associated with providing dental care during pregnancy, Primarily for the protection of the developing fetus, dentists are advised to defer elective dental care during pregnancy, to provide necessary dental care during the second trimester if possible. and to avoid certain medications and drugs. (10, 11) Exposing radiographs is not a serious potential harm in this case as long as standard criteria for these exposures are met and explained to the patient. (10)

What is missing in this case is substantive information about the patient and the reasons for her request. Although she is a minor, does Mary have the capacity for decision-making? This lack of information caused one respondent to write that he had to “make Mary a composite of all possible conditions of her situation that I have seen in the past.” Dr. Jones might believe that it would be “beneficial to Mary if her parents knew and could provide support.&uot; but there is no indication of Mary’s plans for the pregnancy or the reason that she does not want her mother to know. There may be serious family circumstances and consequences that the dentist may not understand — consequences that could cause Mary great harm. Also, Mary’s dental needs, if any, in this care are unclear.

There are no simple formulas for determining the weight of the factors in each case or when it is justifiable to break a patient’s confidence. Although Mary’s case is hampered by the lack of key information, the dentist is still forced to make a decision, especially if Mary needs immediate treatment.

Conclusion

Mary Smith’s case is a compelling ethical dilemma surrounding confidentiality and the conflicting moral issues of respecting the: autonomy of a minor while protecting others from harm. Assuming in this case that Mary requires no further dental treatment. Dr. Jones would be ethically justified in encouraging her to discuss her pregnancy with her mother, but should keep the pregnancy in confidence. However, if Mary required immediate dental treatment, the obligation to protect her confidence would have to be weighed against the risks of harm to others — risks that may justify breaking Mary’s confidence.

References
  1. The Hippocratic Oath, In WHS Jones, trans. Hippocrates. Cambridge, Mass: Harvard University Press; 1923; 1:164-165.
  2. American Medical Association Principles of Medical Ethics. 1980.
  3. Trans Amer Dent Assoc. 1922:137.
  4. ADA Principles of Ethics and Code of Professional Conduct, May 1992.
  5. TDA Principles of Ethics and Code of Professional Conduct, May 1985.
  6. Reiser, SJ. Medical ethics reflected in codes of ethics: the Hippocratic Oath and the 1980 AMA Code compared. J of Texas Medicine 199I: 87(1); 77-81.
  7. Rule, JT & Veatch RM. Ethical Questions in Dentistry. Chicago: Quintessence Pub. 1993: 143-145.
  8. Arnold RM. Presented to West Virginia Network of Ethics Committees. 1992 Summer Intensive Course in Medical Ethics, Davis, West Virginia.
  9. Campbell, CS & Rogers, VC. The normative principles of dental ethics. In Dental Ethics. Edited by B. Weinstein, Philadelphia, Lea & Febiger, 1993; 36-38.
  10. Coleman GC. Nelson JF. Principles of Oral Diagnosis. St. Louis: Mosby Year Book. 1993:258.
  11. Scully C, Cawson RA. Medical Problems in Dentistry. Second Edition. Boston: Wright, 1987; 275-278.

Editor’s Comment: Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry, the National Center for Policy Analysis or the Texas Dental Association.

Reference

The ethical dilemmas presented in Course 2 were originally published in the Texas Dental Journal between 1993 and 1994, and are reprinted with the permission of the Texas Dental Journal. The dilemmas were originally edited by Thomas K. Hasegawa, Jr., DDS, MA, Associate Dean for Clinical Services, Baylor College of Dentistry. Sincere appreciation is extended to both the Texas Dental Journal and Dr. Thomas K. Hasegawa, Jr.

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