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Ethics . . . in the Profession of Dentistry


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Title: Ethics . . . in the Profession of Dentistry

Ethics . . . in the Profession of Dentistry
  • Rocky Mountain
  • Dental Convention
  • Denver, Colorado
  • Janurary 24, 2014

Rodins The Thinker
  • The Thinker, created by Auguste Rodin, noted
    French sculptor (1840-1917), is considered one of
    the worlds great sculptures
  • The Thinker was the capstone piece of a very
    large unfinished sculpture of Rodin, The Gates
    of Hell.
  • The Thinker provides an appropriate visual
    metaphor for our thinking about professional
    ethics.. We will think together about the
    importance and relevance of ethics as to the
    profession of dentistry.

If you wish to converse with me, first define
your terms.
  • Francois Marie Arouet Voltaire

  • What Does It Mean To Be A Member Of A
    Profession A Professional?

  • Professional as
  • Not An Amateur
  • contrasted with
  • The Classical Learned Professions

Learned Professions As Conceptualized
  • Law
  • Medicine. including dentistry as a
    specialty of medicine
  • Clergy

Knowledge Is Power Baruch
Dutch philosopher
  • The concept of profession developed from the
    extraordinary power these groups of individuals
    had over those they served.
  • They were the only literate members of the
  • Law Power over Property
  • Medicine Power over Person
  • Clergy Power over Providence

  • Classically and historically, professionals
    profess (promise, avow) a technical competency
    based on a tradition of advanced
    learning/education for which they will be morally
    accountable in placing this expertise at the
    service of society.
  • The concept of profession is deeply rooted in the
    notion if making a promise to another. The
    promise that I will always use my knowledge to do
    what is in your best interest.
  • Therefore the quintessential quality of the
    professional relationship is

Professional Relationship is Fiduciary
  • To be a fiduciary means to stand is a special
    relationship of trust, confidence or
    responsibility to another.
  • Professionals are in a fiduciary relationship due
    to the power they hold over others power based
    in knowledge. They know when others do not.
  • Therefore, others must trust professionals to use
    the knowledge they have in patients/ clients
    best interest.

The Nature of the Professional Relationship
  • Metaphors are figures of speech in which we use a
    word or expression that is typically used to
    designate one thing is used to designate another,
    thus making an implicit comparison suggestion
    one idea as analogous to another. All the
    worlds a stage.
  • The word covenant metaphorically helps further
    elucidate the nature of the relationship between
    professionals and society

  • The Covenant of the Physician Dentist
  • by William F. May

In its ancient and most influential form a
covenant included...
  • A pledge or promise
  • An exchange of gifts
  • A change of being

Marriage...A Contemporary Covenant
  • Pledge or promise the vows
  • Exchange of Gifts the rings
  • Change of Being husband/wife

Dentistry as Covenant...
  • Pledge or Promise
  • Society promises dentistry a monopoly to
  • Dentistry promises to serve society faithfully
    and well.
  • Exchange of Gifts
  • Society gives dentists a state-supported and
    heavily subsidized education, low interest loans,
    and the privilege of self-regulation.
  • Dentistry gives society its knowledge, skills,
    and talents.

Change of Being
  • Ordinary individuals become dentists.
  • Other individuals become patients.
  • Without patients dentists could not be
  • Without dentists patients could not be
    patients and the the beneficiaries of oral

Covenant Reaffirmed
  • On an individual basis each time two individuals
    meet in which one agrees to be the dentist or
    healer, and the other agrees to be the be healed.
  • The duty of doing good for the patients oral
    health is rooted in the prior covenant of the
    profession with society, as a profession.

  • The patient gives self to the dentist in order to
    be the beneficiary of oral health.
  • The dentist gives self to the patient in order to
    gain the fulfillment of service and receive a fee
    from which to support self and family.

Conceit of Philanthropy
  • Health professionals (dentists) consistently
    proclaim their service to mankind.
  • This idea of service succumbs to the conceit of
    philanthropy when the professionals relationship
    to patients is assumed to be gratuitousrather
    than reciprocal is condescending.
  • There is mutuality/reciprocity in the
    relationship flowing out of the covenant.

The Concept of Profession is a Cultural Construct
  • Culture is the collective, mutually shaping
    patterns of norms, values, assumptions, beliefs,
    standards, and attitudes that guide the behavior
    of individuals and groups, whether those groups
    be families, religions, races, geographic
    regions, nations, businesses, or professions.

  • Norms-what the culture understands as normal
    that which should occur naturally the cultures
    guiding rules or principles.
  • Values-what the culture desires desires create
    purpose- purpose provides meaning.
  • Assumptions-what the culture takes for granted
    what it presupposes, takes for granted.
  • Beliefs-that in which the culture places its
    trust and confidence.
  • Standards-the uniform referents of the culture
    the touchstones used in measuring and evaluating.
  • Attitudes-the emotional intentions of the
    culture what it feels and wills.

Culture and Ethics
  • To describe differences between cultures is not
    necessarily to draw moral conclusions only to
    characterize differences.
  • Of course, one can prefer the characteristics of
    one culture over another. Preferences are not
    (necessarily) morality.
  • French/Chinese Socialism/Capitalism
    African/European Muslims/Jews Profession/Business

The Culture of Dentistry As A Profession
  • Norm - Oral health is a primary good an end in
  • Value - Care and concern for all people and their
    oral health.
  • Assumption - Societal good
  • Belief - Cooperation and reciprocity with society
    can result good for all.
  • Standard - Justice/Fairness
  • Attitude - Egalitarianism

  • Professions are organs contrived for the
    achievement of social ends rather than as bodies
    formed to stand together for the assertion of
    rights or the protection of interests and
    privileges of their members.
  • The organizational component of the
    profession is explicitly meant to emphasize the
    advancement of common social interests through
    the professional association.
  • Abraham Flexner U.S.
    Educator and Reformer of
    Medical Education
  • 1915

  • The core criterion of a full fledged
    profession is that it must have means of ensuring
    that its competencies are put to socially
    responsible uses professionals are not
    capitalists, and they are certainly not
    independent proprietors or members of proprietary
  • Talcott Parsons, professor
  • Harvard University
  • Dean of American Sociology

The Culture of Dentistry As A Business
  • Norm - Oral health as a means
  • Value - Entrepreneurial building a successful
    enterprise profits
  • Assumption - Private good to be maximized
  • Belief - Dentistry as a part of the free
    enterprise system
  • Standard - Marketplace
  • Attitude - Social Darwinism

Tension Between Dentistry as a Profession and
Dentistry as a Business
  • Dentistry has historically understood itself to
    be a profession (and continues to do so), and has
    laid claim to professional privileges. It has
    been understood to be focused primarily on
    serving the oral health needs of patients, with
    the financial gain derived from such being of a
    secondary nature cooperating with patients for
    the patients best interest.
  • Yet, many (most?) dentists today understand
    themselves to be practicing in the marketplace of
    health care, competing for patients to provide
    for the legitimate expenses of conducting a
    practice caring for patients with the primary
    motivation of earning a significant profit for
    their servicesoperating a business.
  • There is difference (a tension) between the
    traditional understanding of the culture of
    profession and the culture of business.

  • A new language has infected the culture of .
    . . health care. It is the language of the
    marketplace, of the tradesman, and of the cost
    accountant. It is a language that depersonalizes
    both patients and health professionals and treats
    health care as just another commodity. It is a
    language that is dangerous.
  • Rashi Fein, professor
  • Health Economics
  • Harvard University

Socrates in Dialogue with Thrasymachus
  • But tell me, your physician in the precise
    sense of whom you were just speaking, is he a
    moneymaker, an earner of fees or a healer of the
    sick? And remember to speak of the physician who
    really is such... "Can we deny then, said I,
    that neither does any physician, insofar as he is
    a physician, seek to enjoin the advantage of the
    physician but that of the patient." Plato The
    Republic, 341 B.C.E.

Distinction Between Social Goods and Consumable
  • An Inquiry Into The Nature and Cause of the
    Wealth of Nations
  • Adam Smith
  • Argued that there are basic social goods upon
    which the free market for consumable goods is
    dependent, and that these social goods should not
    be considered a part of the market economy.

  • Is dental care a social good similar in nature to
    police protection, fire protection,, and basic
    health care? public education, public safety?
  • Or
  • Is dental care a consumable good similar in
    nature to purchasing furniture, electronics,
    vacations, travel, sporting equipment or

Categorical Imperative
  • Act so that you treat humanity, whether in
    your own person or that of another, always as an
    end and never simply as a means.
  • Immanuel Kant German Philosopher
  • 1724-1804

Patients Means or Ends?
  • As a profession, dentists serve the end of the
    well-being of their patients.
  • To place ones own interest above the welfare of
    a patient is to treat a patient as means to the
    dentists ends. The patient becomes an object
    to be used by the dentist in achieving personal
    goals. This is reification treating another as
    an object--dehumaning.
  • Always treat others as ends in themselves, never
    as a means to ones own ends. Immanuel Kants
    Moral Imperative.
  • Clearly we derive financial gain from our lifes
    work, but it is derivative a by-product of us
    fulfilling our promise to our patients as
    professionals that they can always trust us to do
    what is in their best interest.

Patients Means or Ends
  • Dentistry as a business sees the oral health of
    patients, not as ends in themselves, but merely
    means to the dentists personal ends.
  • Dentistry as a business serves the end of
    personal profit for the dentist.
  • Understanding dentistry primarily as a business
    places dentistry in the marketplace where oral
    health care becomes a commodity produced and sold
    for a profit.
  • The business of selling cures undermines the
    classical professional modela model rooted in a
    tradition of caring.

  • Health care is not a commodity, and treating
    as such is deleterious to the ethics of patient
    care. Health is a human good that a good society
    has an obligation to protect from the market
  • Edmund Pellegrino, M.D.
  • Distinguished Bioethicist Georgetown

Factors Collapsing Distinction Between Dentistry
as a Profession and Dentistry as a Business
  • Power differential going away. (Education of the
    populace, Internet)
  • A considerable dimension of dental practice today
    is elective, that is for improved of esthetics,
    and not healthcare in the sense of treating
  • Increasingly traditional professionals are
    working in corporate/business settings. In the
    U.S. 60 of all physicians work for
    corporationswith a profit motive.
  • Business has adopted traditional professional
    standards of putting the client/customer good
    first. The former warning of the marketplace,
    caveat emptor (let the buyer beware) is no
    longer applicable, due to customer guarantees.
  • One American bioethicist, William May, has
    suggested that individuals today stand a better
    chance of receiving fair dealing in the
    marketplace of business than they do in the
    offices of the professions.

A Lingering Question
  • Is a visit to the dentist for care
    substantively different than a visit to the
    Porsche dealership to buy a new car, or to the
    grocery store to purchase food, or to the
    department store to purchase a new suit or
  • If so, how so? Does a distinction, or lack of a
    distinction, result in understanding dentistry
    more as a profession or as a business?

Charles O. Wilson and Enlightened Self-Interest
  • Charles O. Wilson was the CEO of General Motors
    at the apogee of GMs success in the 1950s.
  • While testifying before a Senate Committee he
    made a statement that was subsequently widely
    misquoted as, What is good for General Motors is
    good for the Country.
  • In actuality, he said the opposite, What is good
    for the Country is good for General Motors.
  • Today, what is good for the oral health of the
    American people is good for the profession of
  • However, we must be careful not to believe the
    opposite, that what is good for Dentistry is good
    for the American people.

Defining Profession Summarized
  • Professions emerged in the Middle Ages in Europe
    with the increasing knowledge, and therefore
    power, of the clergy, attorneys, and physicians.
  • Professions profess (promise) to place
    themselves in a fiduciary relationship with their
    constituency. Thus TRUST is the quintessential
    quality of the professional relationship.
  • Professions have traditionally been culturally
    distinct from businesses.
  • Forces are work in the environment that are
    challenging the validity of the concept of
  • Yet, their seems to be an inherent difference in
    the transactional relationship between
    dentists/physicians and their patients, and
    automobile salesmen and their customers.

Defining Ethics
  • ETHICS is a branch of the intellectual and
    academic discipline of PHILOSOPHY.
  • PHILOSOPHY literally means Love of
  • Pondering . . .
  • Wondering
  • Reflecting
  • Questioning
  • Reasoning
  • Speculating ...

About Life
  • Philosophy is everybodys business. The human
    being is endowed with the proclivity to
  • Mortimer Adler 20th
    Century philosopher

  • ETHICS is the branch of the discipline of
    philosophy that studies morality. It is the
    science of the moral. It attempts to answer
    the questions of What should I do? or How
    should I behave?
  • MORALITY is that domain of understanding that
    relates us to our world, and to other humans in
    our world. Moral behaviors are those actions
    that can be evaluated as good or right using
    reasoned, objective criteria.
  • The distinction is between the object of study
    (morality) and the study itself (ethics).

Ethics Is Reflection On the Ultimate Good ... the
Summun Bonum
  • Good and Badness
  • Rightness and Wrongness
  • Virtue and Vice
  • Approval and Disapproval
  • Oughts and Ought Nots
  • Ends and Means
  • Judgments of Value and Judgments of Obligation
  • Goals of Living and Methods of Achieving Those

Ethics Raises Questions of Values
  • What is important?
  • What matters?
  • What endures?
  • What is meaningful?
  • What is worthwhile?
  • What is good?
  • What is right?

  • We are all moralists perpetually, geometers
    (or dentists) only by chance.
  • Samuel Johnson
    English lexiographer

Drawing Distinctions Among . . .
  • Ethics
  • Law
  • Religion

  • Law is the societal institution of binding rules
    Of conduct, with enforcement by the policing
    authority of government
  • Law is public consensus and not infrequently a
    temporary one.
  • Law is predicated on the concept of justice,
    with the scales of justice being the symbol of
  • Justice is the foundational principle of all of

  • However, law is the floor, not the ceiling for
    human conduct.
  • Ethics is higher than the law, but not above the
  • It is ethical (moral) to obey the law, as it is a
    societys best judgment of what is just or fair.
    However, consider that civil disobedience can be
    a moral protest against unjust laws.

  • Platos attempt to describe the characteristics
    of a truly just (and good) society.

  • Literally, religion means a reconnecting or
    reuniting binding together. From the Latin
    reagain, and ligare to connect.
  • Religion is a means of overcoming the
    estrangement or separation man feels from God, or
    in naturalistic religions, Nature.

Is conduct right because the gods command it, or
do the gods command it because it is right?
  • Socrates
  • Platos Euthyphro

  • Thomas Aquinas, the great theologian of the
    Middle Ages, analyzed the question
  • 1. God commands us to do what is right, then
  • a) The actions are right because God commands
    them, or
  • b) God commands them because they are right.
  • 2. If a) then, from moral perspective, Gods
    commands are arbitrary and the doctrine of
    goodness of God meaningless.
  • 3. If b) then, admit standard of right and wrong
    independent of God.

  • 4. From religious point of view, undesirable to
    regard Gods commands as arbitrary, or to give up
    in goodness of God.
  • 5. THEREFORE, even from religious perspective, a
    standard of right and wrong independent of God
    must be accepted.
  • Theory of Natural Moral Law Thomas
    Aquinas 1225-1274 C.E.
  • While various religions may teach and emphasize
    moral concepts, it must be emphasized that
    morality is inherent in the very nature of man.
  • Adherence to the precepts of morality is
    incumbent on humans regardless of the presence or
    absence of any religious commitment.

Two Major Questions of Ethics
  • What is the good life? that is What should I
  • What is right? that is What duty do I have to

  • What is the nature of the good life?

  • What duties does one owe to ones fellow human
    beings . . . in order to live in a civil

  • Man is by nature a political animal.
  • Aristotles term political is the synonymous
    with our usage of the word social.
  • We are not hermits. By nature we live in groups,
    cooperating with one another to survive.
  • We are social animals/beings.

  • Morality, that discipline that relates us to our
    world and other individuals in our world, evolved
    when our early hominid ancestors came to
    understand that rules were necessary for social
  • Rules of cooperation among the species were
    imperatives for survival in a hostile world.

Moral Sense
  • Biological evolution has created in us homo
    sapiens the capacity for empathy, a sense of
    fairness, and a capacity for conflict
    resolutionthe essential requisites for
    developing a moral system.
  • Francis Hutcheson and David Hume, English
    philosophers, writing before Darwin, understood
    humans to have a moral sense that was innate.
  • Contemporary primatologists have confirmed that
    our primate relatives also demonstrate a the
    capacity for empathy, a sense of fairness, and
    capacity for conflict resolution.

  • What if there were
  • no rules of morality?
  • no laws?
  • no police?
  • no courts?
  • no government?

LEVIATHAN Thomas Hobbes 1651
  • A literally a large sea monster mentioned in
    the Book of Job, where it is associated with the
    forces of chaos and evil. For Hobbes it was

The State of Nature (Hobbes)
  • 1. Equality of Need
  • 2. Scarcity
  • 3. Essential Equality of Human Power
  • 4. Self-Interest
  • Resultant A Constant State of War, of One with
  • Where
  • Life is Solitary, Poor, Nasty, Brutish, and

Cooperation Is Essential...
  • . . . to escape the state of nature and to
    live, in an ordered society (safe, stable,
    predictable) where we each can pursue the
    realization of our potential our lifes goals.

Moral Rules Are the Basis for Cooperation
Moral Rules --Examples --
  • Dont Cheat
  • Dont Cause Pain
  • Dont Disable
  • Dont Deceive
  • Dont Deprive of Freedom or Opportunity
  • Dont Deprive of Pleasure
  • Dont Kill
  • Dont Break Your Promises
  • Dont Break the Law (Obey the Law)
  • Dont Fail to Do Your Duty (Do Your Duty)
  • Summarized Dont Cause Others Evil or Harm

  • Moral Rules are rules or principles that no
    rational person would want violated with regard
    to themselves or anyone for whom they cared
    without reason. They are rules that protect the
    individual from suffering or evil at the hands of

Obligations of the Social Contract
  • Our duty, to gain the benefits of an ordered
    society, requires that we set aside our short
    term self-interested inclinations in favor of
    general rules that impartially promote the
    welfare of everyone including ourselves
    (ultimately) rules that are in our enlightened
  • We can do this because others in society have
    agreed to do the same thing, because it is in
    their enlightened (ultimate) self-interest as
  • The social contract is how we escape the state
    of nature and create an ordered society,
    escaping anarchy.

  • The law of naturewhich obliges everyone, and
    reason which is law, teaches all mankind who will
    but consult it, that being all equal and
    independent, no one ought to harm another in his
    life, health, liberty of possessions.
  • John Locke
  • English philosopher
  • 1632-1704

Moral Rules Are Universal, Not Absolute
  • Universality in applying the moral rules means
    that all rational human beings with voluntary
    abilities are to abide by the moral rules.
  • Moral absolutism is the claim that we ought
    never break any moral rule for any reason.

Moral Justification
  • Example Nazi storm troopers at the door of
    the Dutch business where Anne Frank and her
    family are hiding--does one lie to the storm
    troopers, and violate the moral precept, "do not
    deceive," or tell the truth, revealing the hiding
    place of the Frank family, and violate the moral
    rule, "do not deprive of freedom or opportunity?"
    The moral life is ambiguous, and frequently
    requires reflection and justification.

Ethics as a Blunt Instrument
  • Ethics is a fairly blunt instrument, it is not
    a scalpel that cuts sharply.
  • Although precise and rigorous, ethics does not
    enable one to determine that one and only one
    action is moral.
  • Certain alternatives may be ruled out, but not
    infrequently range of possible actions often
    remain that are morally acceptable.

Ethics as a Blunt Instrument (continued)
  • Sometimes all possible actions infringe on one
    moral rule or another.
  • It sometimes becomes a matter of determining
    which is the lesser of two evils, or
  • which moral rule deserves receiving the most
    weight in a particular circumstance.

Moral Justification
  • Everyone is always to obey the rules except when
    impartial, rational people can advocate that
    violating it be allowed.
  • On reflection, the consequences of following a
    moral rule in a situation could result in more
    harm than good.
  • And, as has been indicated, not infrequently, all
    of the options available in a situation would
    result in violating a moral rule.
  • Thus reflection forces consideration (and
    justification) of which course of action will
    result in the greater good or the lesser harm.

Applying Moral Justification
  • Moral Justification suggests that when
    impartial, rational people agree on the
    resolution of a particular moral issue when
    applying the moral rules, then such is morally
  • When they cannot agree, the limits of acceptable
    behavior are determined by what impartial,
    rational people can accept.

Kants Categorical Imperative
  • Immanuel Kant, the 19th century German
    philosopher, helps further characterize moral
    justification with his famous dictum, The
    Categorical Imperative act only on that maxim
    that you would will it as a universal law.
  • If your action in a given circumstance could be
    willed to be universalized, that is, you would
    advocate that all people do what you are
    proposing to do in like circumstances, then you
    could make the claim that you decision is
    impartial and appropriate.

Moral Rules (Duties to Others) Correspond to
Individual Rights
Why Cooperate and Keep the Moral Rules?
  • If we do not live by the moral rules, treating
    others fairly or justly, we cannot expect to gain
    the benefits of living in a ordered society. If
    we make a habit of doing harm or evil to others,
    people will not be reluctant to do harm or evil
    to us.
  • This acknowledgment of the value to ourselves of
    abiding by the social contract with its notion of
    moral rules is traditionally referred to as
    enlightened self-interest.

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

  • Is there a single word such that one could
    practice it throughout life? Confucius replied,
    Reciprocitydo not inflict on others what you
    yourself would not wish done to you.
    China Sixth
    Century, B.C.E.

The Golden Rule
Plato Classical Paganism
  • May I do to others as I would that they
    should do to me.
  • Plato
    Fourth Century, B.C.E

Jesus of Nazareth Christianity
  • Whatsoever ye would that men should do to you,
    do ye even so to them
  • Jesus of Nazareth
    First Century, Common Era (C.E.)

But What Is the Role of Doing Good in the
Moral Life?
  • The Moral Ideals
  • Prevent Evil or Harm

Beach Scenario
  • David playing in the surf
  • do not kill
  • David picking up sea shells
  • no rule of morality violated
  • prevented harm
  • David on the lifeguard stand
  • failed to do his duty

Defining Ethics Summarized
  • Ethics is about how to live.
  • Ethics concerns itself with how one should relate
    to othersthe obligations one incurs from living
    in society. However, it also concerns itself with
    the good lifethat to which one should aspire.
  • Ethics, at its foundation, is about rules of
  • Ethics, as cooperation, focus on the idea of
    reciprocity, frequently designated the Golden
    Rule May I do to others as I would that they
    should do to me.
  • Ethics has evolved as a result of the evolution
    of a moral sense in homo sapiens.
  • Ethics is related to both law and religion, but
    is more basic than either, and to be
    distinguished from both.
  • Ethics is ultimately about justice, that is
    fairness in the social contract. The concept of
    fair treatment of others, and by others,
    including society, is key to understanding ethics.

Professional Ethics
  • is based in the moral rule, do you duty.
  • Ethics in dentistry derives from the role
    dentists assume in agreeing to enter into
    relationships with society generally, and other
    humans individually, to do good for them with
    regard to their oral health.

  • Primary to the concept of profession is
    benefiting society. The moral duty of the dental
    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
    positively promoting the good of patients in
    dentistrys avowed expertiseoral health.
  • Professional ethics in dentistry flows from the
    moral rule to do your duty.

  • In explicating the moral duties of the
    profession of dentistry to society generally, and
    to individual patients specifically, we must
    return to the foundational concept of ethics,
    that is, justice or fairness in relationships.

A Theory of Justice
  • Rawls understands justice to exist in two senses
  • Justice in inter-personal relationships.
  • Distributive Justice, how are the benefits and
    burdens of society to be fairly distributed? or
    what is generally understood and referred to as
    Social Justice and
  • In both senses, Rawls is concerned with justice
    as fairness.

Justice/Fairness in Dentistry
  • Exploring ethics in dentistry forces two major
  • What constitutes justice/fairness in the
    relationship of individual dentists in their
    clinical encounters with patients?
  • What constitutes justice/fairness in the
    relationship the profession of dentistry with
    society at large?

Justice or Fairness in the Individual
Dentist/Patient Encounter
Two Moral Principles Establish Context for the
Dentist-Patient Relationship
  • Principle of Beneficience
  • Do good for the patient by promoting their
    well-beingtheir oral health.
  • Principle of Respect for Autonomy
  • Each person should be self-determining . . .
    the author of his or her own life.

  • The goal of the relationship in which one
    assumes the role of health care
    practitioner/dentist 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 patients 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
  • The dentists primary professional obligation
    shall be service to the public. The competent
    and timely delivery of quality care within the
    bounds of the clinical circumstance being given
    to the needs and desires of the patient, shall be
    the most important aspect of this obligation.
  • Principle One Service to the Public and Quality

Continuum of Beneficence
  • Promote Good
  • Prevent Evil or Harm
  • Remove Evil or Harm
  • Do Not Cause Evil or Harm (Non-maleficence)

Who Decides About Goods and Harms-- Risks and
  • In providing goods or benefits, clinicians in
    dentistry acknowledge there are inherent risks of
  • Philosophically, the professional fee is
    understood as a harm the patient must incur.
  • 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 different from the patients.
  • Whose values should prevail?

Respect for Autonomy
  • Autonomy derives from the Greek and literally
    means self-rule, self-governance... being ones
    own person the author or architect of ones
  • 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
  • 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/Disadvantages
  • Benefits/Risks
  • Recommended Treatment
  • Prognosis
  • Cost

Legal Standard for Adequacy of Information
  • Reasonable Person Standard
  • Disclose the benefits and risks that a
    reasonable person, in what the practitioner knows
    to be the patients position, would be likely to
    deem relevant in deciding whether to accept or
    forego a proposed therapy.
  • Accepted by the courts on the grounds that
    the scope of the standard is not subjective as
    to the practitioner of the patient it remains
    objective with due regard for the patients
    informational needs and with suitable leeway for
    the practitioner's situation.

Lack of Coercion
Modifying Behavior
  • Education
  • Persuasion
  • Manipulation
  • Psychological Coercion
  • Physical Coercion

  • Patients must possess cognitive decision making
    capacity in order to be able to provide an
    informed consent.
  • Decisional capacity requires
  • Possession of a set of values and goals.
  • Ability to communicate and understand
    information, and
  • Ability to reason and deliberate about ones

  • Groups of individuals unable to reasonably
    deliberate (rationally consider) on treatment
    options and provide an informed consent are
  • minors
  • extremely anxious patients
  • mentally ill
  • mentally retarded
  • patients with dementia

Informed Consent
  • Must be emphasized that informed consent is
    primarily a concept of ethics, and only
    secondarily a doctrine of law.
  • With an valid informed consent, a dentist can
    provide most any treatment for a patient.
  • Absent a valid consent, a dentist should not
    provide ANY treatment for a patient.

Informed Consent Logistics
  • A signed treatment plan is not necessarily an
    informed consent.
  • A form with a signature at the bottom is not
    necessarily an informed consent.
  • A signed so-called general consent form is not
    an informed consent.
  • Informed consent does have to be documented.

Veracity (Truthfulness)
  • Some argue that the obligation of veracity
    derives from the principle of respect for
  • Certainly a valid consent to treatment must be
    based on information provided that is truthful.
  • If the relationship between the dentist and
    patient is, in fact, fiduciary, one based in
    trust, such a fiduciary (trusting) relationship
    cannot be established and maintained absent

Legal Opinion Informed Consent
  • John Canterbury
  • Versus
  • William Spence
  • (1972)
  • Every human being of adult years and sound mind
    has a right to determine what shall be done with
    his bodyTrue consent o what happens to ones
    self is the informed exercise of a choice, and
    that entails the opportunity to evaluate
    knowledgeably the options available, and the
    risks attendant on each.

Quality as an Issue of Ethics
  • Quality Defined
  • The degree to which health services for
    individuals and populations increase the
    likelihood of desired health outcomes and are
    consistent with current professional knowledge.
  • Institute of Medicine
  • National Academy of Sciences

Two Dimensions of Quality in Dentistry
  • Does the care recommended meet the professions
    standards of care? That is, is it the type of
    care indicated based of our scientific
    understandings and the patients presenting
    circumstance ?
  • Does the care provided meet the technical
    criteria, structural and procedural, for the
    clinical care accomplished?

Quality and Standards of Care
  • Standards of care (practice guidelines) are
    systematically developed statements to assist
    practitioners and patients in making decisions
    about appropriate health care for specific
    clinical situations.
  • A standard of care includes
  • Goals of therapy
  • Indications for therapy
  • Contraindications for therapy
  • Considered risks

Quality and Standards of Care
  • Standards of care are developed by various
    professional organizations.
  • American Heart Association
  • American Dental Association
  • Dental specialty organizations, such as
  • American Association of Oral and Maxillofacial
  • American Academy of Pediatric Dentistry
  • American Academy of Periodontology
  • Standards of care are typically developed by
    representative clinical committees based on the
    research evidence available for the most
    appropriate management of a given clinical

Quality and Technical Criteria
  • Not only is it a requirement of ethics that the
    recommended therapy be within the professions
    standard of care, but the therapy provided must
    be technically appropriate.
  • Examples of such quality failures include
    overhanging amalgams, fixed prostheses in or
    incorrect occlusion, open margins on fixed
    prostheses, etc.

Major Caveat
  • None of us perform technically perfect clinical
    dentistry all of the time.
  • We are humanwe make mistakes.
  • However, professional ethics requires that we
    acknowledge and correct those mistakes when they
    are identified.
  • Never promise a patient anything except
  • I will be there for you should problems with my
    care develop.

Quality of Care and Lifelong Learning
  • The French call it Linformatique, the explosion
    of knowledge our world is experiencing.
  • 6,000 - 7,000 scientific articles published every
  • 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.

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ADA Principles of Ethics and Code of Professional
  • There are three main components
  • Principles--are aspirational goals of the
  • Code of Conductexpression of specific types of
    conduct required or prohibited
  • Advisory Opinionsinterpretations of the Code by
    the ADA Council on Ethics, Bylaws and Judicial

ADA Principles
  • Patient Autonomy
  • self-governance
  • Nonmaleficence
  • do no harm
  • Benefience
  • do good
  • Justice
  • fairness
  • Veracity
  • truthfulness

  • Fidelity is faithfulness.
  • As indicated previously, the root meaning of
    profession is to profess, to make a promise.
  • Inherent in the promise of the dentist to the
    patient is the commitment to be there for them,
    to place their interest as primary to do for
    them the best that can be done with regard to
    oral health care, and to not abandon them in time
    of need.

  • Abandoning a patient is a moral issue, but
    laws (again, based on the moral principle of
    justice) also apply.

Essential Elements of Abandonment
  • There is an established dentist/patient
    relationship. This is established by minimal
    contact, such as a telephone call to schedule an
  • There is a reasonable reliance on the part of the
    patient that care will be provided.
  • There is a need for care by the patient, such
    that lack of care will result in some degree of

Abandonment Potential
  • A dentist refuses to treat a patient without
    giving necessary and proper notice of
    unwillingness to continue to treat so the patient
    can locate another dentist.
  • A dentist removes self from operatory during a
    procedure, or fails to attend to a patient
    subsequent to treatment.
  • A patient is not observed often enough to
    recognize potentially harmful developments in
    tome to treat.
  • A dentist fails to give proper instruction
    regarding a patients care subsequent to leaving
    the office.
  • A patient of record is in need of urgent care
    other than during office hours and no
    arrangements have been made for the dentist or a
    colleague to see the patient.

Grounds for Terminating Relationships
  • Lack of cooperation by the patient.
  • Lack of agreement on appropriate goals or methods
    of treatment.
  • Intervening illness of the dentist.
  • Lack of payment by the patient.
  • Mutual consent.
  • Actually any reason that is not discriminatory,
    that is, based on race, religion, sexual
    orientation, or HIV status.

Terminating a Patient Relationship
  • Attorneys advise that when there is a desire to
    terminate a relationship with a patient that it
    is wise to sent the patient a certified letter,
    return receipt requested, advising them that as
    of a date two weeks hence (some suggest four
    weeks) you will no longer be able to be their
  • No reason has to be given for the dissolution of
    the relationship.

  • If patients could not trust dentists to conceal
    sensitive information, patients would be
    reluctant to disclose full and forthright
  • The duty to maintain confidentiality is also
    supported by the basic right to personal privacy.
  • The Health Insurance Portability and
    Accountability Act of 1996 (HIPPA) reflects
    societys general concern about the privacy of
    personal health records.

Professional 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
    mismanagement of patients, professional ethics is
    reduced to courtesy within a guild.

  • 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

  • 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 professions covenant
    with society requires the profession to act
    vigorously in maintaining its moral integrity.
  • Depending on the issue, colleagues should be
    reported to the component or constituent dental
    society, or to the state board of dentistry.

Professional Fraud and Abuse
  • Fraud is making false statements or
    representations of material facts in order to
    obtain some benefit or payment for which no
    entitlement would otherwise exist.
  • Abuse is any practice that either directly or
    indirectly results in unnecessary costs.
  • It is estimated that approximately 10 of the
    nations dental care expenditures are based in
    fraudulent and abusive practices.
  • If expenditures for dental care reach 80 billion
    this year, this means that 8 billion is
    fraudulent or abusive.

Types of Professional Fraud
  • Billing for services not provided
  • Billing for unnecessary services
  • Billing for services provided by unqualified or
    unlicensed clinical personnel
  • Knowingly billing for inadequate or substandard
  • Misrepresenting the nature of services provided
  • Waiving of insurance co-payments
  • Soliciting/receiving or offering/paying
    remuneration to induce referrals.

Types of Abuse
  • Failure to follow clinical guidelines or
    standards of care
  • Providing unnecessary or substandard care
  • Violating insurance participation agreements
  • Making false statements or representations

Worth Noting from the ADA Principles and Code
  • Dentist has an ethical obligation to furnish a
    copy of the patients record, including
    radiographs to the patient, at no or nominal
    cost, regardless of whether or not the patient
    has an outstanding balance on their account.
  • Dentists are obligated to become report suspected
    cases of abuse and neglect to appropriate state

Worth Noting from the ADA Principles and Code
  • A dentist may not refuse to treat a patient with
    a bloodborne pathogen, Hepatitis B, C, or HIV,
    based solely on that fact. Not only unethical,
    but also illegal.
  • Dentists are obligated to make reasonable
    arrangements for care of patients not of record,
    when consulted in an urgent care situation.
  • Dentists are obligated to report to an
    appropriate reviewing agency instances of gross
    or continual faulty misconduct by other dentists.

Worth Noting from the ADA Principles and Code
  • It is unethical (and illegal) for a dentist to
    waive the co-payment of a patient who is under a
    third party payment agreement.
  • It is unethical (and illegal) for a dentist to
    alter a date of treatment in order that a patient
    can receive benefits of a dental plan for which
    they would not otherwise have been entitled.
  • It is unethical (and illegal) for a dentist to
    describe a procedure incorrectly on a third party
    payment form in order to receive a fee that would
    not ordinarily would have been paid, or to
    receive a higher fee.

Worth Noting from the ADA Principles and Code
  • A dentist may not advertise or solicit patients
    in any form of communication in any manner that
    is false or misleading in any material respect.
  • The use of fellowships, e.g. FACD, may be
    misleading to the general public and indicate
    special skill or education. Unearned or honorary
    degrees and fellowships should be limited to
    curriculum vitae or scientific papers.

Worth Noting from the ADA Principles and Code
  • Dentists may only announce as specialists in one
    of the nine specialty disciplines approved by the
  • The Supreme Court has ruled that the expression
    practice limited to is the same as specialist
    in and cannot be used except by qualified
  • It is unethical to announce that ones practice
    is limited to cosmetic dentistry or that one is a
    specialist in oral facial pain or
    tempromandibular joint disorders.
  • General dentists may announce all of the areas of
    oral health care they offer, as long as they do
    not say or imply that they are specialists in the
    field. For example, a general dentist may
    indicate that s/he practices general dentistry,
    including pediatric dentistry and orthodontics.

Professional Ethics Summarized
  • Professional ethics is based on the moral rule
    do your duty.
  • In the dentist-patient encounter, the dentist has
    an obligation to treat the patient justly
    (fairly) by providing an oral health benefit
    which is both desirable for the patient and
    agreed to by the patient. This is done by gaining
    a valid informed consent.
  • The dentist also has the obligation to deal
    fairly with the patient by being faithful to the
    promises made to the patient, being honest,
    providing quality care with the standards of care
    of the profession, being impartial in selecting
    and treating patients, safe guarding the
    patients privacy by maintaining confidentiality,
    and not abandoning patients.
  • Dentists have the further ethical obligation of
    maintaining their knowledge and skills current in
    order that their patients are able to receive the
    highest quality care the profession can offer
    based on current scientific understandings.

Discussion and Questions
  • David A. Nash D.M.D., M.S.,
  • William R. Willard Professor of Dental Education
  • Professor of Pediatric Dentistry
  • College of Dentistry
  • University of Kentucky
  • Email
  • Telephone 859.323.2026

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A Theory of Justice
  • Rawls understands justice to exist in two senses
  • Justice in inter-personal relationships.
  • Distributive Justice, how are the benefits and
    burdens of society to be fairly distributed? or
    what is generally understood and referred to as
    Social Justice and
  • In both senses, Rawls is concerned with justice
    as fairness.

Social Justice
  • Rawls understanding of the nature of justice
    (fairness) in social context
  • Famous hypothetical veil of ignorance
  • Rational humans designing a world into which they
    would be born, based on a natural lottery, would
    be somewhat risk aversive, and would, therefore
    create a world with three conditions
  • All would have equal rights and liberties.
  • Equal skills and abilities will have access to
    equal access to the various positions of society
    and the most important one for our consideration
    today. Resulting differences in status and
    welfare would be unfortunate, but not
  • Social and economic institutions would be so
    arranged as to maximally benefit the worst off.

Social Justice and Dentistry
  • Given a Rawlsian view of justice/fairness, the
    profession of dentistryas a social (and
    economic) institutionand one with a virtual
    monopoly to practice, has an obligation to work
    for a health care scheme that permits the worst
    off in society to gain the benefits of oral
  • Rawls contractarian approach to justice in
    (oral) health care can also be supported when
    viewed from the perspective of the three other
    major theories of justice utilitarianism,
    egalitarian, and libertarian.

Access to Care
  • To what extent do the socially underprivileged in
    America have maximum access to the professions
    resources to assist them in gaining and
    maintaining the benefits of oral health?
  • In the United States, the disadvantaged have the
    worst oral health and the poorest access to care.
    Such is clearly an issue of social justice.
  • Such calls into question the reciprocity of the
    profession with society, therefore an issue of
    justice as fairnessan issue of ethics.
  • Society grants dentistry a monopoly to practice
    with the potential for significant financial
    gain. Does dentistry reciprocate by ensuring
    that all members of the society have access to a
    decent, basic minimum of oral health care?
  • An understanding of social (distributive) justice
    forces the question of how to translate
    dentistrys social duty into practical reality.

Access to Care
  • The European Enlightenment of the eighteenth
    century brought new social and political
    understandings. Among these was the appreciation
    and valuing of self-interest.
  • However, there was also the realization that our
    person, private good is ultimately grounded in
    the good of others. Thus emerged the notion of
    enlightened self-interest.
  • It is in our enlightened self-interest as a
    profession to be concerned about access to care.
  • The monopoly to practice that society has given
    us can be taken away.
  • Increasingly, public health advocates, leaders in
    forming public policy, and legislators are
    becoming concerned about our professions
    inability or unwillingness to ensure all members
    of society have access to the care we can

Access Initiatives
  • Dental therapists are currently practicing in
    remote Alaskan villages, providing basic dental
    care under the general supervision of a dentist.
    53 countries of the world utilize two year
    trained dental therapists to help address access
    to care problems.
  • American Dental Hygienist Association is
    aggressively promoting their Advanced Dental
    Hygiene Practitioner. Legislators in Minnesota
    have filed a bill on their behalf authorizing
    such an individual to be trained and to practice
    in Minnesota.
  • I have advocated adding a Pediatric Oral Health
    Therapist to the dental teama person working
    with the dentist to care for childrens teeth.
  • Absent aggressive action by our profession to
    deal with this issue of social justice, I
    anticipate we will see efforts by society to
    ensure all have access to dental care through
    methods that are non-traditional.

  • What is the nature of the good life?

  • Life must be lived forward
  • bu