Do Patients and Dentists See Ethics the Same Way? Part 1

The most common approach to ethics in dentistry and bioethics generally is through principles. To be effective, principles must be interpreted in particular situations and the skill of interpretation requires many years of practice with feedback. The opinions of 91 dentists and 54 patients regarding multiple potential actions and justifications for these actions were gathered for eight dental ethics cases. The summary responses of dentists and patients have been integrated as feedback in an online ethics education exercise that individual dentists can use (see www.dental ethics.org/idea/). The dataset of responses was also analyzed for general findings. It emerged that patients and dentists agree to a substantial extent on the average approaches, but differ systematically on certain details. Some ethical issues stimulated a narrow range of responses while others, especially those of a non-clinical nature, were regarded as ambiguous and are thus good candidates for future ethics training. A factor analysis revealed a five-dimension structure underlying dental ethics. Patients are most apt to view dentistry using a lens of oral health outcomes while practitioners prefer to stress the process technical dimensions of practice. The largest area of difference was patients’ much greater interest in dentists assuming an active role as patient oral health advocates with their colleagues.  

There are troubling situations in dentistry where there is reason to follow one course of action and also reason to pursue a contrary path. This is one of the characteristics of a profession that calls for the highest levels of skill and integrity. Doing the wrong thing for the wrong reason can undo beautiful technical work and biological acumen. Deciding whether to honor a patient request (respect for autonomy) for a treatment that is of questionable value (nonmaleficence) is a problem that arises from time to time. Deciding whether to take action, and if so what action, and for what real motives, when a colleague’s work is pretty regularly seen to be below the standard of care is a test of loyalty – to the profession and to the public. These are called ethical dilemmas because there is something worthwhile to be said on both sides of the matter. Other times behavior is simply wrong but tempting. It is hard to think of circumstances that would justify overtreatment, upcoding insurance claims, or permitting a hostile work environment, but it happens. Although these are not dilemmas, we might still expect to see a range of behavior, supported by interpretations of particular circumstances and personal value systems. Patients bring their own moral standards to the table. Some are likely to be sensitive to and speak up about particular tough choices dentists face and overlook others. Some patients use highly personal ethical maps. Those who are not patients — including public policy makers, bloggers, and those who vigorously avoid dentists — cannot be prevented from having opinions about what is right and wrong in dentistry.   

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In the past few decades, the professions have addressed these issues under the heading of “principles.” An ethical principle is an abstract standard for appropriate behavior. Veracity (truth telling) and justice (fair distribution of benefits and burdens) are examples. The Belmont Report, the first comprehensive (1979) American statement of ethical policy in medicine, identified three principles: respect for persons, beneficence, and justice. (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979).¹⁸ The field of bioethics exploded in the years following, and Tom Beauchamp and James Childress’s Principles of Biomedical Ethics has become the fundamental expression of professional principlism.² Beauchamp and Childress’s four cardinal principle are

1. respect for autonomy,
2. nonmaleficence,
3. beneficence, and
4. justice.

The American Dental Association added a fifth principle, veracity, which accounts for about 40% of the Code of Professional Conduct and covers mostly dentist-to-dentist issues. The American Society for Bioethics and Humanities uses a code with seven principles. The American Bar Association identifies eight. The American Medical Association Code of Ethics has nine principles. Principles offer general guidance, but they are blunt instruments. Specific issues can often be categorized under more than one principle, and these sometimes “guide” action in contrary directions. The tension between conflicting principles is well known. Both the ADA, in their Principles of Ethics and Code of Professional Conduct, and Beauchamp and Childress acknowledge this, and professionals are usually counselled to “use their personal judgment to reach a ‘balanced’ resolution.” The problem is that there is no principle that determines when “balance” has been achieved.²³ Principles need some form of further support to finish the job.¹³ The bulk of ethics training – both in dental schools and where it appears occasionally in CE formats – as well as codes of conduct are intended as interpretations of the principles. This is sometimes called the Ethical Syllogism.¹⁵ It works like this:

• Major Premise – Beneficence consists in doing what is best for the patient.
• Minor Premise – If patients are only informed of treatment options that I favor based on my training, they will pick sound treatments.
• Conclusion – It is beneficent to steer patients in informed consent toward optimal oral health.

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[su_pullquote align=”right”]Not all practitioners interpret ethical principles the same way. [/su_pullquote]There are no debates in dentistry over whether respect for autonomy or justice, for example, are sound ethical principles. They are. All of the discussion turns on whether specific behaviors are best interpreted as good examples of the principles. Learning to become a professional entails learning how one’s colleagues interpret the principles.

Despite their open-endedness, principles are a solid place to start in ethics training for professionals. Particular problems can be examined through the lens of multiple principles to give them depth and to reduce the chance of overlooking something important. Some interpretations of specific cases are clearly wrong and others are among the several alternative acceptable options. Interpretation is necessary, but all interpretations are not equally valid. Becoming a mature ethical professional means a long period of study of a wide range of concrete cases and gradually building interpretative skill. The principles can be memorized in less than a minute; becoming an ethical professional requires a lifetime of practice.

Not all practitioners interpret ethical principles the same way. A doctrinaire insistence on the letter of the law in the kingdom of one’s own office may satisfy the urge of consistency. Some dentists use a shallow grounding in ethics because they are confident that they can “just do the right thing.” It would be easy to maintain these positions if patients, staff, and associates can be dismissed for not seeing things as the owner dentist does. In fact principles may not even be necessary in such cases. Being a professional means contributing to and learning from the collective wisdom of one’s colleagues, and other important people. Principles begin to play a useful purpose when dentists look to their colleagues and others to see whether better alternatives exist. Ethics becomes part of the language in the conversations that make it possible to grow professionally. Absent comparisons of specific ethical cases, practitioners are apt to stagnate at the level of moral maturity they had when leaving dental school or even earlier in their lives.  

It may come as a surprise that there are no American journals for dental ethics. Of the more than twenty in various professional fields, there are multiple examples in medicine, nursing, law, business, clergy, education, and even the military services. This is very likely a reflection of the fact that all of these professions are practiced in public settings. Since 1998, accreditation standards for U.S. dental schools require documented compliance with the standard that students “must be competent in the application of the principles of ethical decision making and professional responsibility”.8 This is managed in some schools by an hour or sometimes several hours of seminar discussion of cases. This is not enough.3

There are several theories of moral development. James Rest has modified and extensively studied Lawrence Kohlberg’s developmental stages model of moral reasoning.19,14 There are three levels in this characterization of ethics, each having to do with the reasons one uses in reaching moral decisions (and less so with the actions themselves). Rest identifies these levels as:

• Pre-Conventional, where the standard is to follow authority and do what is rewarded and avoid what is punished;
• Conventional, do what your peers expect of you; and
• Post-Conventional, where abstract norms are weighted as a philosopher might.

I will use the more descriptive labels: “self,” “group,” and “ethics” as these appear to capture where individuals orient for finding the ultimate standard for ethical decision making in various cases.

The challenge is to create a safe environment for all dentists who traditionally work in isolation to compare notes, try alternatives, and get feedback to build moral skill. We need a platform for interaction, and it needs to be pretty large, open to all, and easily available 24/7 for extended periods of time.

As a step toward creating an opportunity for dentists to engage in public interpretation of prototypical ethics cases, the American College of Dentists has created a set of eight cases for discussion. These are available in written form and will soon be available in video format. But there is a significant limitation to the effectiveness of reading about ethics. There should be some way of experimenting with options and learning what one’s colleagues would do. Perhaps it would even be useful to know what a representative sample of patients thinks of these situations.

Okay, let’s find out. There are two goals in this course:

1. introduce a platform for building interpretative skills in practical ethics for practitioners that can be accessed conveniently from one’s office and
2. begin to understand the norms patients and dentists hold regarding various aspects of dental practice.

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