#57424: Dental Ethics: A Brief Review

Under the deontologic umbrella, an action is deemed right or wrong according to whether it follows pre-established criteria known as imperatives. An imperative in our language is viewed as a "must do," a rule, an absolute, a black and white issue. This is an ethic based upon duty linked to absolute truths set down by specific philosophical schools of thought. If the principles dictated by these imperatives are met with dutiful compliance, one is said to be acting ethically.

One of the most significant features of deontologic ethics is found in John Rawls' Theory of Justice, which states that every person of equal ability has a right to equal use and application of liberty. However, certain liberties may be at competition with one another. There are also some principles within the same ethical theoretical system that can conflict with one another. An example of this conflict might involve a decision over allocation of scarce resources. Under the principle of justice, all people should receive equal resources (benefits), but allocation can become an ethical dilemma when those resources are scarce.

The precepts in the deontologic system of ethical decision making stand on moral rules and unwavering principles. No matter what situation presents itself, the purest deontologic decision maker would stand fast by a hierarchy of maxims. They are as follows [18]:

The teleologic ethical theories or consequential ethics are outcome-based theories. It is not the motive or intention that causes one to act ethically, but the consequences of the act [19]. If the action causes a good effect, it is said to be ethical. So here, the end justifies the means.

The motivist would say that there are no theoretical principles that can stand alone as a basis for ethical living. Motivist belief systems are not driven by absolute values, but instead by intentions or motives. It is not the action, but the intent or motive of the individual that is of importance. An example of a motivist ethical theory is rationalism. Rationalism promotes reason or logic for ethical decision making. Outside directives or imperatives are not needed as each situation presents the logic within it that allows the user to act ethically.

Natural law ethics, also known as the virtue system of ethics, is a system in which actions are considered morally or ethically correct if in accord with the end purpose of human nature and human goals. The fundamental maxim of natural law ethics is to do good and avoid evil. Although similar to the deontologic theoretical thought process, it differs in that natural law focuses on the end purpose concept. Further, natural law is an element in many religions while at its core it can be either theistic or non-theistic.

In theistic natural law, one believes God is the Creator, and the follower of this belief sees God as reflected in nature and creation. The nontheistic believer, on the other hand, develops understanding from within, through intuition and reason with no belief rooted in God. In either case, natural law is said to hold precedence over man-made law.

The total development of the person, physically, intellectually, morally, and spiritually, is the natural law approach. Therefore, ethical decision making should not be problematic, as judgment and action should come naturally and habitually to the individual follower of natural law.

Although appearing to be the perfect approach to all ethical situations requiring decision making, there are some significant drawbacks; for example, a person's maximum potential is relative or subjective. Additionally, what constitutes natural law? The precept to do good and avoid evil leaves a very large space for interpretation. Because it acts largely outside of individual wishes, often separating human life into a set of separate events, it is an impersonal approach, devaluing the focus upon dignity. To some, it is also a rather cold-hearted approach—not making decisions with an individual, but for the individual based upon what others believe to be good for that person. The principle of paternalism would fit within this context.

The transcultural ethical theory is a modern ethical system of thought that centers on the diversity of cultures and beliefs among which we all live. Therefore, at its core, this ethic assumes that all discourse and interaction is transcultural due to the strengths and differences in values and beliefs of groups within society.

The advantage to the transcultural ethical system is that it folds parts of the other ethical systems together while recognizing the differences between people. A disadvantage might be that Western society largely follows the deontologic and teleologic principles that also make up the legal system. Therefore, there may be some difficulty in making decisions based upon other cultural beliefs and values. Our society largely operates on a basis of facts, conclusions, and predetermined, agreed-upon solutions based upon male Anglo-American ideals. Many healthcare professionals may find difficulty with the transcultural ethic's reliance on close inter-relationships and mutual sharing of differences required in this framework.

The ethical theory of relativism/multiculturalism falls under the postmodernist philosophical perspective and may be referred to as moral relativism [16]. Multiculturalism promotes the idea that all cultural groups be treated with respect and equality [17]. According to ethical relativists, ethical principles are culturally bound and one must examine ethical principles within each culture or society [16]. The question then becomes how ethical principles that are primarily deontologic and rooted in Western values are applicable in other societies. The challenge of ethical relativism is how to determine which values take precedent [16].

Autonomy refers to the right of the patient to determine what will be done with his or her own person (i.e., self-governance). It also involves the patient's right to have confidentiality of his or her own medical history and records, and for the medical personnel to safeguard that right. The dentist should involve the patient in treatment decisions in a meaningful way, with due consideration being given to the patient's needs and desires [1].

Ozar, Sokol, and Patthoff present four possible models of the patient-dentist relationship [3]:

Of these, the interactive model represents the ideal dentist-patient relationship [3]. In this model, the dentist and patient each have standing and deserve each other's respect, and each has a set of values by which to live. In addition, each comes to the decision-making process about the patient's oral health with the understanding that information must be shared. This can only be achieved through communication and mutual cooperation. They summarize [3]:

Federal privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other healthcare providers took effect on April 14, 2003. Congress called on the U.S. Department of Health and Human Services (HHS) to issue patient privacy protections as part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA includes provisions designed to encourage electronic transactions and requires new safeguards to protect the security and confidentiality of health information [4].

These standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent consistent federal privacy protections for consumers across the country [4]. The HHS has issued extensive guidance and technical materials to explain the privacy rule, including an extensive, searchable collection of frequently asked questions that address major aspects of the rule. HHS will continue to expand and update these materials to further assist covered entities in complying. These materials are available at https://www.hhs.gov/hipaa.

The efficiencies of electronic recordkeeping are obvious. There is, however, a downside that accompanies these efficiencies, including inappropriate and unknown-to-the-patient data transfer resulting from numerous linked locations, such as third-party financial entities and employers. As paper-based recordkeeping has transitioned to electronic, the risk of unintentional privacy violations related to new-user lack of expertise has increased. Precautions should also be in place to prevent intentional misuse of patient data. This presents an additional burden for dentists and other healthcare providers from both internal staff (on-site) and external service providers (off-site), not to mention deliberate electronic intruders.

Veracity involves truthfulness and keeping promises. Dental professionals are obligated to be truthful with patients and/or their families and to avoid withholding information or representing care in a false or misleading manner. Dentists should avoid making representations or suggestions to their patients for treatment that is not based on scientifically accepted principles or research. It is unethical for a dentist to recommend unnecessary dental procedures to their patients.

Beneficence refers to the ethical principle of doing or promoting good. Community service, in the form of offering free dental care to the needy, is one example of how a dentist can elevate the esteem of the profession. The Academy of General Dentistry requires that Lifelong Learning and Service Recognition Candidates complete at least 100 hours of approved dental-related community/volunteer service, such as community education panels and the provision of pro bono patient care, or service to organized dentistry [13].

In addition, when a dental professional has achieved, through research or investigation, results that promote or safeguard the health of the public, he or she has an obligation to share those results with the profession. This does not prevent a dentist from seeking copyright or patent protection.

Assessment for and identification of abuse is another example of practices to promote good. Orofacial trauma is common in cases of abuse, and in most states, dental professionals are obliged to report patients with symptoms consistent with domestic violence and child or elder abuse. The dentist is often the first healthcare provider to treat the victim and is therefore ideally positioned to provide intervention by reporting to the appropriate authorities and offering information on domestic violence shelters and other resources to patients.

Nonmaleficence simply means that dental professionals must try to avoid doing harm to the patient. It is the duty of the dental professional to evaluate his or her own skills and recognize when further education is required or when referral to a specialist is in the best interest of the patient. A dentist must complete a patient's treatment once it has begun or make arrangements for appropriate care if for any reason the dentist cannot complete the care.

Dental professionals who continue to practice while using substances that impair their ability to practice or who suffer from mental or physical impairment are not acting ethically and are violating the law. Colleagues of an impaired dental professional (e.g., in the case of substance abuse) should report the individual to the professional assistance committee of their dental society.

Dentists who are consulted for a second opinion should not have a vested interest in the recommended treatment. According to the ADA's Principles of Ethics and Code of Professional Conduct, when delegating patient care, the dentist is required to protect the health of the patient using only qualified auxiliary personnel while prescribing and supervising the patient care. A dentist may delegate remediable tasks to dental hygienists and dental assistants so long as delegation of the task poses no increased risk to the patient and the task may be legally delegated. In general, tasks that may be delegated are those that do not create unalterable changes in the oral cavity or contiguous structures, are reversible, and do not expose a patient to increased risks. The use of a laser or laser device of any type is not a remediable task [1].

All dentists, regardless of their bloodborne pathogen status, have an ethical obligation to immediately inform any patient who may have been exposed to blood or other potentially infectious material in the dental office of the need for postexposure evaluation and follow-up [1]. They are obligated to immediately refer the patient to a qualified healthcare practitioner who may provide postexposure services. The dentist's ethical obligation in the event of an exposure incident extends to providing information concerning the dentist's own bloodborne pathogen status to the evaluating healthcare practitioner if the dentist is the source individual, and to submitting to testing that will assist in the evaluation of the patient. If a staff member or other third person is the source individual, the dentist should encourage that person to cooperate as needed for the patient's evaluation.

Dentists should avoid personal relationships with their patients, as the potential for exploitation cannot be overstated. The judgment of what may be in the patient's best interest may be impaired where there is a personal relationship. Dentists should be sensitive to the patient's perception of inappropriate behavior [1].

Justice is broadly understood as fairness; however, it also pertains to what someone or a group is owed. It implies fairness in relationships and dealings with patients, colleagues, and society. It also relates to the distribution or allocation of a scarce resource or treatment without prejudice. Ozar, Sokol, and Patthoff write, "when a society's structures for distributing resources are ethically sound, a common adjective used to describe the society is just. When a society's structures are ethically deficient, one proper term is unjust" [3]. Distributive justice, coined by Aristotle to describe the effort to determine which kinds of distributive structures are ethical and which are not, could also be called social justice as it applies to dentists, dental patients, and society's distributive structures [3].

Dentists shall not refuse to accept patients into their practice or deny dental service to patients because of the patient's race, creed, color, sex, gender identity, or national origin [1]. Dentists should also avoid discrimination when making referrals to other dental professionals and in their hiring practices. According to Ozar, Sokol, and Patthoff, the primary considerations when making referrals are the specialists' technical expertise, communication skills, manner, and philosophy of dental practice [3].

A dentist may, in the course of his or her career, be called upon to provide expert testimony in the disposition of a judicial or administrative action. When a dentist has a poor result or outcome with his or her own patient, this may be difficult. When a patient presents for treatment with a poor result from another dentist, it is even more difficult. Dentists must have the ability to work with colleagues to achieve results that improve or maintain the patient's oral and general health. When a second opinion is sought, the patient's second dentist must take care to provide criticism that is justifiable. Avoidance of disparaging remarks to the patient about the first dentist's work cannot be overstated. The second dentist must balance this with his or her obligation to the profession when determining "whether the bad work is symptomatic of a potentially harmful pattern on the part of the first dentist and what sort of response is then appropriate" [3].

Legal cases in dental care do not always involve malpractice that results in the injury and/or death of a patient. There have been several cases of dental Medicare/Medicaid fraud in the news. Although most insurance errors are the result of simple mistakes, cases of deliberate fraud ultimately undermine the dental profession and cost consumers millions of dollars in higher healthcare costs and health insurance premiums.

There are several federal and state laws to deter and punish those who defraud (or seek to defraud) Medicare and Medicaid, including the False Claims Act, the Anti-Kickback Statute, and the Criminal Health Care Fraud Statute [11]. Those who commit healthcare fraud are subject to a penalty of 10 years imprisonment and a substantial fine. If serious bodily injury has occurred, the violator may be sentenced to 20 years, and if death has occurred, the sentence may be life imprisonment [11].

In 2010, a New York Attorney General indicted four individuals and three corporations on charges of stealing upwards of $5.7 million from the Medicaid system out of dental clinics in Brooklyn, Queens, and the Bronx [20]. The defendants owned the clinics (but were not dentists themselves, and therefore are prohibited from owning a dental clinic) and employed many dentists who were instructed to encourage patients, often homeless and lured by recruiters with McDonald's gift cards, CD players, and cash, to agree to high-value and quick-turnaround procedures (e.g., complete tooth extraction and denture fitting in the same office visit). The employed dentists were required to pay two-thirds of the Medicaid billings to the three corporations involved in the suit.

In 2013, a dentist practicing in Connecticut (who was previously barred from practicing in every other state in New England) was sentenced to eight years in prison and ordered to pay $10 million in fines and restitution for operating a number of assembly line-style clinics that performed unnecessary dental procedures targeting poor patients and collecting more than $20 million in fraudulent claims from Medicaid [7]. The clinics hired recruiters to canvas neighborhoods and paid bonuses to those who brought in patients. In some cases, transportation was arranged for patients to the clinics, which were located in low-income neighborhoods. Most of the unnecessary procedures involved drilling into perfectly healthy teeth but included other questionable treatments. The plaintiff had relocated to Connecticut following the announcement of a program to increase Medicaid payments in an effort to induce more dentists to treat low-income patients. The dentist hid his involvement in the Connecticut clinics by using false names and false corporations and by falsifying documents.

In 2019, a dentist based in Los Angeles, California, was sentenced to 40 months in prison for his role in a $3.8 million healthcare fraud scheme in which he billed numerous dental insurance carriers for crowns and fillings that were never provided to patients [10].

In the past decade, there has also been a focus on dental professionals who inappropriately prescribe and/or bill insurance carriers for unnecessary medications—particularly opioid analgesics [6]. In 2017, a dentist in Pennsylvania was charged with hundreds of counts of charges of distribution of hydrocodone and oxycodone (Schedule II and III controlled substances) outside the usual course of professional practice; using or maintaining a drug-involved premises; healthcare fraud; and omitting material information from required reports, records, and other documents [6].