Dental Ethics at Chairside

2020-2021 OzarHasegawa Dental Ethics

Student: Luljeta Isedisha DMD AS 2021 candidate Faculty Advisor: Catherine Frankl Sarkis, JD, MBA Boston University Henry M. Goldman School of Dental Medicine

Case 

Dr C is a recent graduate who has been working in a well- established general dentistry practice for the past year. He provides a wide range of treatments for all ages and has gained the reputation of a caring and competent dentist, whom patients appreciate a lot.

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One day, after many emergencies and long procedures he was scheduled to see Ms. Y to replace an amalgam restoration on #12 due to recurrent decay. He has been seeing this patient for other restorative procedures and they get along well.

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After anesthetizing the patient, he goes to do a periodic exam for a patient being seen from one of the hygienists in the office.

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When he comes back, removes the old amalgam and at one point after finding no caries asks the assistant to open the x-ray.

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At that point he realized that instead of #12 he had actually removed the restoration on #13 which also happened to be amalgam.

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The dentist stops the procedure and is facing the dilemma of how to proceed next.

Why this case? 

Seems like a small dilemma but one that can happen often if we are not careful and vigilant during treatment

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The ethical issue is very clear in this case, but it is the way it will be addressed that will set the cornerstone of the professional you will be.

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As professionals we are entrusted by society to provide the best care for our patients by combining technical skills, knowledge and application of ethical principles.

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Every time before I run my handpiece; this is my first though, let me double check, let me triple check to make sure I have the right tooth before I do something that cannot be undone

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That is why this seemingly minor case appeals to me, because it can happen to any of us. Even though it was just a hypothetical situation revolving around the possible scenarios really made me think deeply about how our actions as dentists can influence the life of our patient.

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By applying the ethical issues and professional obligations to the care provided help me as a future dental professionals to build up on how to deal with my patients and these situations effectively

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This is a mental exercise that every professional should run through their mind, in order to be prepared when the real situation comes or better even to be able to prevent it by being mindful of the possible consequences.

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It is these small decisions that will build the foundation of our ethics and professionalism

Ethical issue

HOW SHOULD THE DENTIST ADDRESS THIS SITUATION WITH THE PATIENT

Step 1: Identify the Alternatives

COURSES

OUTCOME:

OF ACTION AVAILABLE AND THEIR LIKELY

1.

STOP THE PROCEDURE, NOTIFY THE PATIENT OF WHAT HAPPENED AND THEN PROCEED

2.

CONTINUE THE PROCEDURE ON #13 AND PLACE THE COMPOSITE RESTORATION AND NOT INFORM THE PATIENT

3.

COMPLETE BOTH #13 AND #12 BUT INFORM THE PATIENT AFTER AND ONLY CHARGE PATIENT FOR #12

4.

FINISH RESTORATION ON #13, NOTIFY THE PATIENT, NO CHARGE FOR THE TREATMENT AND ASK IF THEY FEEL COMFORTABLE TO COME BACK AND FINISH #12 ANOTHER SESSION

1.

Stop the procedure, notify the patient of what happened and then proceed

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Considering the patient has seen this dentist for some time and is happy with the rendered services, chances are he will appreciate the straightforwardness and honesty and the option to make their own decision

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The communication, previous relationship, honesty, willingness to make up for what happened will most likely determine the outcome of the situation

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A thoughtful reflection on the dentist behalf will go a long way and reach the patient to make them understand that this occurrence is the exception and not the rule

2.

Continue the procedure on #13 and place the composite restoration and not inform the patient 

While this can save you at the moment, it will be discovered sooner or later

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At some point in time, you will have to address what happened

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Whether it be with the patient themselves or when they realize they did not get the treatment they needed and were hidden the truth

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This not only would undermine the doctor- patient relationship but would possibly have other ethical and legal repercussions

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Not talking to the patient because of fear of creating a debate with patient/ owner / other colleagues will make you look even worse when all is uncovered

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Sure, there is the chance nobody will realize what happened (your assistant does) but will you be able to make peace with your conscience for what occurred

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It will speak highly of you for owning your mistakes and accepting what happened

3.

Complete both #13 and #12 but inform the patient after and only charge patient for #12

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Not wanting to alert the patient during the procedure you go ahead and finish the treatment for both teeth without giving the patient the option to choose

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You explain to the patient that you removed a restoration which was not needed, and you replaced it without incurring additional charges

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You also finished the treatment for the tooth that required treatment=> so you addressed the problem

4. Finish restoration on #13, notify the patient, no charge for the treatment and ask if they feel comfortable to come back and finish #12 another session

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This would resolve the issue of removing the restoration on #13 unnecessarily and will give the patient the opportunity to make their own decision about continuing with further treatment

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It will make the patient feel that they have some control over the situation and how to move forward

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It will also instill trust in the doctor- patient interaction

Step 2: Determine What is Professionally at Stake 1.

Obligation to inform patient about dental mistake and allow them to make an informed decision about the continuation of care

2.

Providing substandard care and hiding information from patient- doing harm and not disclosing it- ethical and legal repercussions

3.

Not offering the patient a chance to make their own decision. Trying to make it up by not adding the additional cost of treatment that was not needed

Step 3: Determine What Else is Ethically at Stake 1.

Veracity on behalf of the dentist and Autonomy by the patient to make a decision

2.

Nonmaleficence principle ignored and possible implications for patient and dentist

3.

Beneficence / Justice

1.

Veracity on behalf of the dentist

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Veracity means being honest and telling the truth to the patient in any situation. This creates the bases for trust in the relationship between the patient and their provider. It is a dual agreement that the patient is expected to be truthful as well as the healthcare provider and together they can reach to a mutual agreement about treatment goals.

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This principle is closely related to the ethical principle of autonomy, which means that the patient after being informed truthfully of all associated aspects of case can make an educated decision in their own best interest.

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In this case, we expect Dr C to apply the ethical principle of Veracity and disclose to the patient what happened during the procedure.

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The clinician should disclose the mistake, the patient options, advantages and disadvantages of each, any associated cost and any other relevant factors that will help the patient make a decision.

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The patient, Ms. Y then will apply the principle of autonomy to make a decision on how she feels more comfortable to proceed next.

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That is why is important to be truthful, as it will give the patient a sense of security and understanding as you are standing up for your mistake.

2. Autonomy by the patient to make a decision 

Autonomy is the ethical principle that respects patient’s ability to make their own decision based on their needs.

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As health care providers we may face ethical dilemmas where autonomy of the patients conflicts our professional reasoning and, in these cases, it is paramount to respect the autonomy of patients and inform them of all the aspects of care they are being provided.

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In this case, it is important for Dr C to provide his patient with all the information regarding what happened during the procedure and any implications associated with it.

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Even thought the dentist may feel it is in the patient's best interest to finish the restoration on #13 without letting the patient know as soon as they realized the mistake, it would be preferrable for them to inform the patient first and then proceed.

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Once the patient is given all the necessary information, they can make an informed decision about the continuation of the procedure and express their autonomy.

3.

Nonmaleficence principle ignored and possible implications for patient and dentist

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Nonmaleficence as a principle states that the first obligation we have as healthcare providers is: Do no harm( primum non nocere). The patients entrust us with the highest privilege of providing care and in turn expect no harm. The healthcare provider should maintain their knowledge up to date and be skilled in certain procedures and when it is beyond their capability to refer the patient as needed.

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This ethical principle encompasses that the provider should not inflict harm, should prevent harm from happening, remove harm from patient and promote good for the patient. These steps can serve as a hierarchy for the provider to follow in cases of ethical dilemmas during the practice of dentistry.

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Referring to this principle the Dentist Dr C having inflicted harm upon the patient should now focus on removing harm from them and promoting beneficence by replacing the lost restoration.

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Ideally the dentist would not have caused harm to the patient but since that happened it is important to follow the above hierarchy to decide about his following actions. Therefore, now Dr C should focus in removing harm from the patient and promoting his wellbeing.

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This can be done by replacing the restoration that was wrongly removed and eventually treating the dental caries on the adjacent tooth.

4.

Beneficence

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Beneficence is the ethical principle that promotes actions that result in good consequences. It means to take the necessary actions to restore the patient to health. Therefore, the dentist as a healthcare provider should be skilled to identify the harm and remove it to ensure the patients wellbeing.

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It is closely associated with nonmaleficence principle. The dentist must do all in their power to Do Good for the patients..

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In the mentioned case, Dr C must restore the patient to health to abide by the beneficence principle. This means that not only should he restore the tooth that was wrongly prepped but should also address the caries on #12 as it could progress and cause harm to the patient if left untreated.

5. Justice 

The principle of justice states that the individual should be provided with what they deserve.

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Applying this principle to the case mentioned revolves around the fact that some harm was done to the patient and it is just that the patient be rewarded accordingly.

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It could be limited to restoring #13 at no charge and/or additional modifications as agreed between the dentist and the provider.

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It is not always that straightforward especially in cases where the damage is more extensive, and it is hard to determine the exact value the patient should be rewarded because it may go beyond physical harm.

stop procedure, inform patient about what happened, based on patient's decision finish only #13 at no charge and restore #12 at same appointment or following appointment.

Step 4: Determine What Ought to be Done ranking of the alternatives in the case

finish #13 , notify patient, no charge and then ask patient if would like to come back for #12

Complete both #13 and #12 and inform patient after.

Charge only for #12

Complete procedure on #13 and not inform the patient of anything

Stop procedure

Step 5: Choose a Course of Action

Inform the patient, apologize for what happened

Explain that you will replace the restoration you removed at no charge

Allow them to make the decision if to proceed with treating #12 at the same session or they would like to come back another appointment

Summary 

Dentists as healthcare professionals hold a privileged status in society. Due to the status that has been given to them by the society the patients expect the highest level of care from their provider and trust them with their health. Therefore, the dentist should hold themselves accountable to provide patients with the standard of care and keep their skills up to date.

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Comprehending the ethical principles and obligations that come with being part of a profession will ensure the dentist will deal appropriately with dilemmas and ethical issues that arise during everyday practice.

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Dentists should evaluate these situations, discern right from wrong, ethical from nonethical actions, standard vs substandard care and so on. Then as professionals they should commit to go through careful decision making and assess professional and ethical obligations associated with the care they provide.

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There are many tools the dentist can use as a guide to solve these ethical dilemmas and make a decision. One of the most useful ones is David Ozar’s model of ethical decision making.

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This is a ready formula that will ensure a good decision is made and will help the professional uphold

References 

Ozar DT, Sokol DJ, Patthoff D. Dental Ethics at Chairside: Professional Obligations and Practical Applications, 3rd edition. Washington, DC. Georgetown University Press. 2018.

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American Dental Association. Principles of Ethics and Code of Professional Conduct.

Thank you!