“Man ultimately decides for himself, and in the end, education must be education toward the ability to decide.”

Viktor Frankl Austrian psychotherapist

THE ETHICS OF PROFESSION

“As A Dentist, Should I Live Differently Than The

Ordinary Person, And If So, How and Why?

Terminal Objective

The dentist will choose to apply the principles of professional ethics to his or her practice of dentistry.

Enabling Objectives

The student dentist will be able to:

• define the principle of beneficence and explain the dentist's role in applying the principle in caring for patients.

• relate nonmaleficence to beneficence.

• describe the principle of respect for autonomy.

• describe the three ingredients of a valid or informed consent.

• explain the relationship of gaining a valid consent from patients to the ethical principles of beneficence and respect for autonomy.

• explain "paternalism."

• justify a dentist's ethical obligation to "lifelong learning."

• apply the two aspects of Rawl's principle of justice to the practice of dentistry.

• explain why there exists a societal expectation for self-regulation in the learned' professions generally, and dentistry specifically.

Professional Ethics in Dentistry Based on the

Moral Rule...

“Do Your Duty”

Profession

• Moral Component

• Intellectual Component

Just as in Aristotle’s Concept of the Virtues, Based on the Nature of Human-kind.

Moral Component of Profession

Primary to the notion of profession is benefiting society. The moral component of profession is doing good for the oral health of our patients and society. The moral rule of not causing harm becomes the moral ideal of preventing evil or harm by the promoting the good of patients in the area of dentistry’s avowed expertise…oral health.

The Troika of Principles of

Professional Ethics

We promote oral health by observing three principles of morality:

• Beneficence

• Respect for Autonomy

• Justice

Beneficence

The goal of the relationship in which one assumes the role of health care practitioner and the other patient is the benefiting of the patient. This benefiting is accomplished by the dentist providing the highest quality of care possible contingent on the professions current scientific understanding, the clinical circumstances, and the patient’s desires.

Hippocratic Oath

“I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.”

ADA Principles of Ethics and Code of

Professional Conduct

“The dentist’s primary professional obligation shall be service to the public. The competent and timely delivery of quality care within the bounds of the clinical circumstances presented by the patient, with due consideration being given to the needs and desires of the patient, shall be the most important aspect of that obligation.”

Principle One

Service to the Public and Quality of Care

Continuum of Beneficence

Promote Good

Prevent Evil or Harm

Remove Evil or Harm

Do Not Cause Evil or Harm

(Non-maleficence)

Non-Maleficence

Who Decides About Goods and Harms-- Risks and Benefits?

In providing goods or benefits, clinicians in dentistry acknowledge there are inherent risks of harms. Dentists have the duty to weigh benefits against possible harms, and minimize the risk of harms. But the dentists conception of benefits and risks may be diffenent from the patient’s.

Whose values should prevail?

Respect for Autonomy

Autonomy derives from the Greek and literally means self-rule, self-governance... being one’s own person; the author of one’s life. The moral rule, “do not deprive of freedom or opportunity,” means it is moral or right to grant self-governance to others.

Informed Consent

• Adequate information, with adequate understanding

• Lack of coercion

• Competence

Adequate Information

with

Adequate Understanding

• The concept of adequate information/understanding can deteriorate into a mechanical rehearsal of data to legally protect the dentist unless tempered with the idea of patient comprehension. This is done by processing information reciprocally; asking for patient understanding and validation of the information.

• Adequate information/understanding does not require that the patient be told everything there is to know, but only the information adequate to make an ‘informed decision;’ information that a reasonable person would want to have/

Adequate Information

• Nature of the Problem (Diagnosis)

• Goals of Treatment

• Alternatives in Treatment

• Advantages/Diadvantages

• Benefits/Risks

• Recommended Treatment

• Prognosis

• Cost

Lack of Coercion

Modifying Behavior

Education

Persuasion

Manipulation

Psychological Coercion

Physical Coercion

Paternalism

Assumptions:

• Acting Beneficently … Doing Good

• Violating a Moral Rule

• Patient has not given an Informed Consent

• Patient is Competent to give Consent

Competence

Groups of individuals unable to reasonably deliberate (rationally consider) on treatment options and provide and informed consent are:

– minors– extremely anxious patients– mentally ill– mentally retarded– patients with dementia

Justice

The Theory of Justice

John Rawls

Concept of Justice

“… When a number of persons engage in a mutually

advantageous cooperative venture according to rules, and

thus restrict their liberty in ways necessary to yield

advantages for all, those who have submitted to these rules

have a right to similar acquiescence on the part of

those who have benefited from their submission.”

A Theory of Justice

John Rawls

Two Facets of Justice

1. “Each person is to have an equal right to the most extensive liberty compatible with a similar liberty for others - giving to each his/her right or due.”

--Justice as Fairness --

2. “Social and economic inequities are to be arranged so that they are both:– Reasonably expected to be everyone’s

advantage, and– Attached to positions and offices open

to all.”

--Social Justice --

Justice in Individual Relationship

• Dentists have an obligation to treat their patients fairly by:

– assessing a reasonable fee.– providing a quality service.– attending to the patient in time of

need.– by honoring all aspects of the

profession’s covenant with society.

Self-Regulation and Justice

• Professional self-regulation is an onerous obligation, and difficult to achieve. The duty to colleagues seems, at least superficially, to take precedence over the obligation to patients in matters of professional incompetence.

• To the extent that concern for other dentists prevails over concern for the clinical mismanagment of patients, professional ethics is reduced to “courtesy within a guild.”

• However, a cautionary note is advised. It is a violation of the autonomy of colleagues, that is a limiting of their freedom or opportunity, if comments are made, or actions taken, without complete surety of the facts of the case.

• Documentation of repeated breaches of professional behavior by colleagues demands that the “whistle be blown.” The profession’s covenant with society requires the profession to act vigorously in maintaining its moral integrity.

“In order to guarantee to the public that certain standards shall be maintained, the state limits the license to practice to those who have completed a course of professional education. Professionals as a group profit from this state-created monopoly. They fall short of their responsibilities for the maintenance of standards if they merely practice competently and ethically as individuals. The individuals license to practice depends on the prior license to license, which the state has, for all intents and purposes, bestowed on the profession. If the license to practice carries with it the obligation to practice well, then the license to license carriers with it the obligation to judge and monitor well. Not only the individual, but also the collectivity (profession) itself is accountable for standards.”

William F. May

Social Justice

Refers to the Justified

Distribution of Benefits

and Burdens of Society

Oral Heath As A Societal Good

• Water fluoridation

• Access to care

• Oral health information

• Community sealant programs

• Any activity or oral health promotion and disease prevention.

Intellectual Component of

Profession

Life Long Learning

• Philosophical End

• Psychological End

• Practical End

Philosophical End

• Aristotle’s concept of “intellectual virtue.” We fulfill one of our vital functions as human being when we continue to learn.

• “we must cease conceiving of education (learning) as mere preparation for later life, and make it the full meaning of present life…an activity that does not have worth enough to be carried out for its own sake cannot be effective as preparation for something else.”

John Dewey American philosopher

Psychological End

• Maslow’s concept of “being all you can be.” As we are by nature learning animals, we actualize our potential when we learn.

• Csikszentmihalyi’s concept of “flow.” Having our intellectuality exercised and stretched with new ideas, challenging concepts, and exciting understandings is to get in, and be in, flow.

Practical End

• A competent professional in dentistry must apply the profession’s current knowledge base to patient care with integrity. Standards of care must be fulfilled, and those standards are continuously changing through research.

• The half-life of dental knowledge has been estimated to be 5-7 years.

L’informatique

• 6,000 - 7,000 scientific articles published every day.

• Now … scientific and technological information increases 13% /year -- doubling every 5.5 years.

• Rates of information expansion will soon increase 40%/year due to more powerful information system and the increasing population of scientists.

• Then … the scientific information will double every twenty months.

“If we indoctrinate our students in an elaborate set of fixed beliefs, we are ensuring their early obsolescence. The alternative is to develop skills, attitudes, habits of mind, and kinds of knowledge and understanding that will be instruments of continuous change and growth. Then we will fabricate a system that provides for continuous renewal.”

John Gardner

in Self-Renewal