EDUCATIONAL OBJECTIVES

After reading this course, the participant should be able to:

1. Identify the ethical principles used in health care for framing ethical problems and questions.
2. Explain the difference between beneficence and nonmaleficence.
3. Describe how autonomy supports the ethical and legal mandate of informed consent in health care.
4. Relate how distributive justice can affect dental care and health care in the United States.

Dental hygienists face ethical questions and dilemmas throughout professional practice. These problems arise when the clinician is challenged between competing obligations and has to weigh two or more possible options to resolve the situation. What guidance does the clinician have in these kinds of situations? 

Applying ethical principles can assist the clinician in addressing ethical questions or dilemmas. More specifically, what is the good or proper choice in a specific situation? Health care principles provide a cognitive framework for analyzing ethical questions and problems. These principles are linked to commonly expected behaviors because they are based on shared standards of thinking and behaving. In health care, the basic ethical principles are nonmaleficence, beneficence, autonomy, and justice. These principles are associated with expectations for behavior, and they provide guidelines for dealing with situations where a choice among right and wrong options may exist or when no option is available that is clearly right or wrong. 

What is an Ethical Dilemma? 

There is a difference between addressing everyday problems and addressing ethical dilemmas. An ethical dilemma occurs when one or more ethical principles are in conflict. An example of a true ethical dilemma is when the principle of nonmaleficence is in conflict with the principle of autonomy in a specific situation. For example, a patient with a cardiac problem for whom the American Heart Association recommends antibiotic prophylaxis before invasive dental hygiene procedures tells the dental hygienist to just go ahead with the scaling and root planing because he does not want to take any antibiotics. The patient is expressing his autonomy by stating he does not wish premedication. The dental hy gien ist, however, knows that a lack of antibiotic coverage may cause harm to the patient. This is a genuine ethical dilemma because two ethical principles (patient autonomy and nonmaleficence) are in conflict. 

Resolving an ethical dilemma is certainly a different enterprise from solving daily problems such as which instrument to choose for scaling a patient with periodontitis. It is also different from the situation where an individual is knowingly and intentionally charging an insurance company for dental procedures that were not performed. This clearly involves unethical and unlawful behavior (fraud), but it is not a true ethical dilemma because principles are not in conflict. 

In a perfect world, the needs and wants of the patient would always come first and there would be no conflicts, no disputes, and no dilemmas for the dental hygienist or any health care provider. However, this is not the case in a real world where what seems to be in the patient's best interest may differ between the clinician and the patient or among the patient, the patient's family, or other health care professionals. Principles and values in health care help guide decisionmaking in the process of providing the best oral health care for the patient. 

Principle of Nonmaleficence 

The founding principle of all the health professions is nonmaleficence. This principle declares that a health care provider's first obligation to the patient is to do no harm. Patients are placing themselves in the care of another person and, at a minimum, they expect that no additional harm will result from the treatment. Another person is given the privilege of access to a portion of the patient's body for an explicit purpose and this privilege is founded in trust. Fundamental to this trust is that the health care provider will do no harm to the patient. 

Glossary of Terms  

Autonomy: the quality or state of being selfgoverning
Beneficence: doing or producing good
Justice: the maintenance or administration of what is just especially by the impartial adjustment of conflicting claims or the assignment of merited rewards or punishment
Nonmaleficence: not committing harm or evil
 

Definitions provided by Merriam Webster Online. 

Though nonmaleficence is primarily concerned with doing no harm, over time it has evolved to include preventing and removing harm. Therefore, not only do health care providers have an obligation to do no harm, but they also have an obligation to prevent harm. Prevention of harm is clearly within the domain of dental hygienists. Dental hygienists are concerned with preventing harm when universal precautions are observed, when scaling and root planing are performed to preserve teeth and periodontal tissues, and when educating patients about oral health care. Similarly, dental hygienists remove harm when they treat patients who have active periodontal diseases. 

Does prevention of harm mean all possible harm? A very narrow interpretation would hold that complete avoidance of any pain and suffering in patient care must be maintained. This view would mean invasive diagnostic tests to locate disease as well as intra-oral injections to allow scaling and root planing could never be performed. Consequently, patients would never benefit from treatment that would alleviate current pain nor could they benefit by preventing future pain and suffering. This narrow view is an unrealistic application of nonmaleficence. A health care provider may not always be able to avoid harm. In fact, causing some degree of harm when the harm will lead to a greater good—restoring a patient to health—may not only be desirable, but necessary. This conflict is referred to as the concept of double effect, and requires the health care provider to consider the risks and benefits whenever treatment is provided.1 

What comprises harm and good can be expanded into the following classification: 1. Not to inflict harm 2. Prevent harm 3. Remove harm 4. Do or promote good 

The first level in this classification encompasses avoidance of harm or nonmaleficence and takes precedence over the second, third, and fourth levels, which define beneficence, the promotion of good. This explanation of nonmaleficence and beneficence gives the clinician a guideline to help sort out the relationship of this duty. Not inflicting harm takes precedence over preventing harm while removing harm comes before promoting good. It is not always possible to totally avoid harm and promote goodness in the practice of dental hygiene and dentistry. 

Principle of Beneficence 

Whereas nonmaleficence is concerned with doing no harm to a patient, beneficence requires that existing harm be removed. Beneficence focuses on "doing good" for the patient. Doing good requires taking all appropriate actions to restore patients to good health. Health care providers, based on their knowledge and skill, will use all reasonable means to benefit the patient. 

Beneficence and nonmaleficence are often linked because they are both founded in the Hippocratic tradition that requires the physician to do what will best benefit the patient. Clinicians doing what they think will best benefit the patient implies a consequence analysis to determine the best possible outcome for the patient. 

Beneficence is found in all health care codes of ethics. By choosing to become a dental hygienist, an individual assumes a responsibility to help others and professes to be part of a profession, which requires that his or her actions, behaviors, and attitudes are consistent with his or her commitment to public service—a commitment to benefit others. This commitment to assist and benefit others defines the healing professions morally and sets them apart from other occupations such as architecture or engineering.2 

For the dental hygienist who is greatly focused on prevention and preventing oral diseases, promoting good is an everyday purpose and goal. For any person who is in a position to increase the good of others, eg, health care providers, failure to increase the good of others is morally wrong. The purpose and very existence of biomedical research, public health policies, and programs and preventive medicine are the formalized aspects of this phase of health care. Society—through various federal, state, and communitybased activities—attempts to meet this need for good of the public. The promotion of good becomes difficult when good is defined from differing values and belief systems. Careful oral hygiene self-care to maintain health and function is the promotion of good to many people. However, the removal of all carious teeth to eliminate pain and suffering could be considered good to other individuals. In public health programs, the appropriation of limited resources to great medical and dental needs in a population can be challenging and frustrating. 

Principle of Autonomy 

An Ethical Dilemma Within the Principle of Autonomy 

It would be ethical to refuse a patient's request to extract all healthy teeth even though the decision would conflict with the patient's autonomy. Dentists and dental hygienists should avoid doing harm to a patient even if the patient is exercising autonomy by asking to receive a potentially harmful treatment or service. 

Autonomy is self-determination and the ability to be self-governing and selfdirecting. An autonomous person chooses thoughts and actions relevant to his or her needs independent from the will of others.3 In health care, autonomy is what gives rise to the concept of permitting individuals to make decisions about their own health, and it is the heart of many ethical dilemmas that occur in dentistry. Because dental hygienists have such a wide range of knowledge and skills, they must fully and adequately explain the parameters of services that can be performed and the consequences of applying or not applying those services. 

The principle of autonomy is based on respect for individuals. The health care provider has a duty to provide the patient with all the unbiased information a patient needs to make a decision about treatment options, which is informed consent. This is an area in which there is potential for conflict between what the dentist and/or dental hygienist believes is in the best interest of the patient and what the patient believes is in his or her own best interest. Sometimes what the professional believes is best for the patient is not what the patient chooses to do. As long as the patient selects from treatment options that are consistent with the standards of care, the professional may ethically act on the patient's choice.4 However, the professional also has the autonomy to not provide a service that is requested by the patient if that service is in conflict with the accepted standards of patient care. See the sidebar for an example of an ethical dilemma related to the principle of autonomy. 

Principle of Justice 

The principle of justice is concerned with providing individuals or groups with what is owed, due, or deserved. Frequently the foundation of justice is described as the principle of equality: likes should be treated alike, equals should be treated as equals, and unequals treated as unequals. The obvious problem in this approach is that there must be some mechanism or criteria for determining who is equal or unequal. If an individual is unequal, is he or she entitled to the same type and quality of health care as the "equals?" Would that be just? 

Fundamental to the principle of justice is fairness, an effort to treat people who have similar needs in a similar or the same manner.5 Patients who seek treatment for the prevention of periodontal diseases should receive the same level of care and attention from the dental hygienist regardless of personal or social characteristics. 

Justice in dentistry is most often discussed in terms of public policy issues and is further referred to as distributive justice. Every society must address the problem of how its resources are distributed because every society has a scarcity of resources. Resources are scarce whether referring to materials, specially trained people, time, or other factors. Distributive justice is concerned with the allocation of resources in large social systems.6 Policy makers must confront the issue of how society distributes its resources. Who gets what and why? This has implications for national health care policy and is a continuing source of difficulty for health care providers, public policy administrators, and the greater community at large. 

Applying Principles and Values 

The basic ethical principles in health care are guides for the dental hygienist and health care providers in determining what is right and wrong in the practice of health care. From these principles flow the rules that are laid out in all codes of ethics and codes of professional conduct. How these principles and codes are applied to decision making is the challenge for each health care provider faced with a professional problem or dilemma. These principles and values can provide the dental hygienist with guidance in the decision making process. Although these are good guides to use, they do not automatically provide correct ethical decisions because they are sometimes in conflict with each other. A choice has to be made based on the specific case or circumstances and after thoughtful analysis and consideration of the alternatives and consequences to choosing a particular course of action. 

Some philosophers and authors may use different approaches to identify principles and values used in health care. Often, veracity (truth-telling) is listed as one of the five major principles rather than as a dimension of autonomy. Codes of ethics can also be developed around concepts that may be structured differently using similar words. The Code of Ethics of the American Dental Hygienists' Association (ADHA) has established five principles: universality, complementarity, ethics, community, and responsibility, in addition to seven core values: autonomy, confidentiality, trust, nonmaleficence, beneficence, justice, and veracity as the basis on which the standards of professional responsibility are built. Whether it is called a principle or a value, the concept is fundamental. 

The fundamental principles of ethics— nonmaleficence, beneficence, autonomy, justice—are commonly used to assist in the decision making process. These principles and concepts are intellectual tools that can guide the dental hygienist in making difficult decisions when confronting ethical problems and dilemmas. 


 

Belmont Publications, Inc. is an ADA CERP Recognized Provider 

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. 

 

Phyllis L. Beemsterboer, RDH, MS, EdD, is professor and associate dean for Academic Affairs in the School of Dentistry at Oregon Health & Science University (OHSU) in Portland, Ore. She is an associate director in the Center for Ethics in Health Care at OHSU and cochairs the interprofessional ethics education program. Her research interest is in bioethics, especially academic integrity and the use of cases in the teaching of ethics in dentistry. An active member of the American Society for Dental Ethics, Beemsterboer has written a number of textbooks including a text about ethics and law that is used in dental hygiene education programs. 

References 

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press Inc; 2001.
2. Beemsterboer PL. Ethics and Law in Dental Hygiene. 2nd ed. St. Louis: Saunders Elsevier; 2010.
3. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 4th ed. New York: McGraw-Hill; 1998.
4. Ozar DT, Sokol DJ. Dental Ethics at Chairside: Professional Principles and Practical Application. 2nd ed. Washington, DC: Georgetown Press; 2002.
5. Purtilo R. Ethical Dimensions in the Health Professions. 4th ed. Philadelphia: Saunders Elsevier; 2005.
6. Rule JT, Veatch RM. Ethical Questions in Dentistry. 2nd ed. Chicago: Quintessence Publishing Inc; 2004.
 


From Dimensions of Dental Hygiene. December 2009; 7(12): 44-47.

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