Imagine that you have purchased a dental practice from a senior dentist who has recently retired. You notice that the quality of the dentistry you see in the patients is not up to the standard that you practice.
What do you do? If you repeat the dentistry, it will involve extra expense to the patient and put them through the discomfort of undergoing extra procedures. How will you explain to the patient why the dentistry, some of which was done recently, needs to be replaced. This could leave the previous dentist open to criticism and possibly legal action. You may find yourself in court as a prosecution witness. Worse, the retiring dentist’s lawyers may take action against you claiming your criticism was both unfair and designed to increase demand for your services. You have heard that patients do not think more highly of dentists who criticize other dentist’s work, but rather post-criticism see all dentists in a lesser light. They wonder if the criticizing dentist is more interested in financial gain than in their patient’s welfare.
On the other side of the coin, shouldn’t you tell the patient? Doesn’t the Hippocratic Oath state that you should keep the patient from harm and injustice. Hasn’t the patient a right to know? The situation you face is an ethical dilemma.
Such a case has recently occurred where a retiring dentist has faced multiple legal cases after criticism and replacement of his work by the dentist who purchased his practice.
According to the FDI, as members of a profession dentists have duties and responsibilities over and above other citizens. A common reason given for this extra responsibility is that there is an imbalance of power and knowledge between the dentist and the patient. At the same time as being a profession, dentistry is a commercial enterprise and there is tension between the two concepts.
To make your decision even more difficult, individuals disagree amongst themselves about what is right and what is wrong. What is ethical varies among different religions, between different cultures, and over time. On what basis should you be making your decision? Many ethical issues arise in dental practice for which there is little guidance. You will be ultimately responsible for making your own ethical decisions and for implementing them.
One way to make ethical decisions is to use what are called non-rational approaches such as obedience, imitation, feeling or desire, intuition and habit. Obedience was used during the post-war Nuremburg trails of Nazi leaders and is known as the “Nuremburg defence,” where morality consists of following orders of those in authority, whether you agree with them or not. Imitation consists of using role models: You may look towards the behaviour of your parents or of senior dentists. Feeling or desire is a subjective approach. What is right is what feels right or satisfies one’s desire. There is an old adage of “when in doubt, it is probably not ethical.” The FDI suggest this adage is a good personal guideline1. Intuition is similar to desire in that it is subjective. It is different in that it directs moral decisions through a simple flash of insight. Habit is a very efficient method of moral decision-making because you don’t have to think. However, there are bad habits as well as good ones and as ethics change over time, continuing with the same habit may no longer be appropriate.
Another type of approach to making ethical decisions is to use rational approaches. Deontology involves a search for well-founded rules. Often there is no room for disagreement. This approach is often used in religion. An example is Christianity with its 10 commandments. Consequentialism is based on the principle that the right action is the one that produces the best outcomes: “The ends justifies the means.” However, there can be disagreement about what are the best outcomes. Virtue ethics focuses less on the decision-making and more on the character of the decision-makers, but virtuous people are not immune from making wrong decisions. Principlism uses ethical principles as the basis for making moral decisions.
Hippocrates (ca. 460 BC – ca. 370 BC) – was an ancient Greek physician, who is considered one of the most outstanding figures in the history of medicine. He is referred to as the “father of medicine” in recognition of his lasting contributions to the field as the founder of the Hippocratic school of medicine. The following four principles based on the Hippocratic Oath capture most of what is at the centre of ethics in dentistry.
All actions should demonstrate:
- regard for self-determination (respect for autonomy)
- the avoidance of doing harm (nonmaleficence)
- the promotion of well-being (beneficence)
- fairness in the distribution of goods and harms (justice).
The FDI based its International Principles of Ethics for the Dental Profession1 on the Hippocratic Oath. According to the FDI, the primary duty of the dentist is to safeguard the oral health of patients. Hence, the dentist should refer for advice or treatment any patient requiring a level of dental competence greater than he/she possesses, must ensure professional confidentiality of all information about patients and their treatment, should continue to develop professional knowledge and skills, and should support oral health promotion. The dentist should also be respectful towards professional colleagues and staff, and should act in a manner which will enhance the prestige and reputation of the profession.
However, if a colleague has performed poor dentistry, the “the needs of the patient” may be in conflict with the principle of being “respectful towards professional colleagues”. It is difficult to explain that a patient’s existing dentistry is poor without criticising their previous dentist.
So what should you do? If the reason for replacing the work is for financial gain, that is unethical and shouldn’t be done. You also need to decide that even if the dentistry is not up to the standard you wish in your patients and whether replacement of the dentistry will be to the patient’s benefit. If you decide that the work does need to be replaced, ethically you should outline all the necessary information, but refrain from disparaging the previous dentist publicly or to the patient, except where the criticism is justifiable, such as, gross and continual faulty treatment. You also have an ethical and legal responsibility to report grossly unethical or unprofessional conduct.
 Williams JW, Principle features of ethics. In Dental Ethics Manual, FDI World Dental Federation www.fdiworlddental.org., 2007.
Dr Len Crocombe, Guild Liaison Group