Ethics and Code of Conduct in Dentistry Notes
Overview of Ethics and Code of Conduct in Dentistry
The study of ethics in the dental profession is fundamental to the conduct of every member of the dental team, including dentists, hygienists, and dental assistants. As representatives of their specific professions and the team as a whole, dental professionals must adhere to standards that often exceed legal requirements.
Definition of Ethics: Ethics serves as a guide for determining what an individual should do in life. It involves the philosophical study of moral values and conduct.
The Study of Ethics: This field focuses on two primary questions:
What should I do?
Why should I do it?
Ethics versus Law:
Laws: These are specific, codified rules that must be followed.
Ethical Standards: These represent a higher order of conduct than the minimum legal standards required by law. While laws mandate the bare minimum acceptable behavior, ethics strive for the ideal or most moral behavior.
Sources of Personal Ethics
Personal ethics are developed and learned throughout an individual's life from infancy through adulthood. These internal moral compasses are shaped by several key sources:
Basic Instinct: Reaching internal conclusions about right and wrong.
Parents: Early childhood guidance and the instillment of values.
Teachers: Influence through formal education and mentorship.
Religion: Theological frameworks and spiritual guidance that define moral duties.
Observation of Other People’s Behavior: Learning through social interaction and witnessing the consequences of others' actions.
Five Fundamental Principles of Dental Ethics
The American Dental Association (ADA) Code of Professional Conduct identifies five core principles that serve as the foundation for ethical dental practice. These principles guide interactions between the dental team and their patients.
Patient Autonomy (Self-Governance):
Definition: Respecting the patient's right to self-determination and confidentiality.
Application: Relates to the patient’s ability to make their own choices regarding their treatment and healthcare, provided they are informed.
Nonmaleficence (Do No Harm):
Definition: The obligation of the professional to protect the patient from harm.
Application: This affects the conduct of the dental team by requiring them to keep knowledge and skills current and to know their limitations when referring patients.
Beneficence (Do Good):
Definition: The professional's obligation to act for the benefit of others.
Application: Professionals in dentistry are obligated to provide high-quality care and contribute to the well-being of the public and the profession.
Justice (Fairness):
Definition: Treating all people fairly and without prejudice.
Application: This affects others by ensuring equitable distribution of healthcare resources and fair treatment for all patients regardless of background.
Veracity (Truthfulness):
Definition: The obligation to be honest and trustworthy in all professional relationships.
Application: This affects the patient by ensuring that the dentist-patient relationship is built on trust, specifically regarding diagnosis and treatment options.
Professional Code of Ethics for Dental Assistants
Dental assistants are governed by voluntary standards set by fellow members of the profession. These codes help define the professional life and conduct of the assistant.
ADAA Principles of Ethics: Professional standards established by the American Dental Assistants Association.
ADAA Code of Member Conduct: Specific rules regarding the behavior and professional behavior of ADAA members.
CDAA Code of Ethics: The code governing members of the Canadian Dental Assistants’ Association (where applicable).
Practical Applications of Ethical Principles
Ethical principles are applied daily in clinical and educational settings. The following scenarios illustrate how these principles may be violated or upheld:
Principle of Justice (Fairness): An example of a violation would be charging a patient for a full set of x-rays when only films were actually taken. This constitutes unfair financial practice.
Principle of Autonomy (Self-Governance): Pressuring a classmate into making a specific decision violates their right to self-determination and independent choice.
Principle of Well-being (Beneficence): Refusing to help a classmate learn is a failure to fulfill the obligation to promote the welfare of others within the profession.
Principle of Doing No Harm (Nonmaleficence): Harming another person by repeating gossip about them is a professional and personal violation of the mandate to avoid causing harm.
Steps for Solving Ethical Dilemmas
Ethical dilemmas occur when one or more ethical principles are in conflict. To process these dilemmas effectively, a four-step framework is utilized:
Step 1: Identify the Alternatives: Determine the various courses of action that could be taken in the situation.
Step 2: Determine All Implications: Evaluate the potential consequences (positive and negative) for each alternative identified.
Step 3: Rank the Alternatives: Prioritize the potential actions based on which most closely aligns with the core ethical principles.
Step 4: Choose a Course of Action: Select and implement the most ethical path forward.
Statutory Law in Dentistry
Definition and Categories: Statutory law is divided into two primary categories which define legal responsibilities and consequences in the dental field:
Criminal Law: Involves crimes committed against society. Legal classifications include:
Felony: A serious crime.
Misdemeanor: A less serious offense.
Infraction: A minor offense.
Civil Law: Involves injury to an individual or a company. Sub-branches include:
Contract Law: Deals with binding agreements.
Tort Law: Deals with civil wrongs or injuries.
Administrative Law: Deals with regulations created by government agencies.
The Board of Dentistry and Licensure
The State Board of Dentistry:
Members are appointed by the governor of the state.
Also referred to in some states as the "Dental Board."
Functions: The board adopts rules and regulations that define, interpret, and implement the intent of the State Dental Practice Act. They are responsible for regulating and enforcing the laws of practice within that specific state.
Licensure Purpose: The primary goal of licensure is to protect the public from unqualified or incompetent practitioners.
Practicing dentistry without a license is a criminal act in every state.
Licensure by Credential: This allows an individual who is currently licensed in one state to become licensed in another state without further education or typical requirements, provided specific state-mandated criteria are met. Requirements for this process vary by state.
The State Dental Practice Act
Primary Purpose: To protect the public from incompetent practitioners by specifying the legal requirements for practicing dentistry within each state.
Typical Contents of the Act:
Requirements for initial licensure.
Requirements for license renewal.
Grounds for the revocation or suspension of a license.
Requirements for continuing education.
Identification of duties that can be delegated to dental auxiliaries.
Infection control regulations.
Requirements for the use of radiation and the specific qualifications required for health professionals who expose dental radiographs.
Implementation: An administrative board (usually the Board of Dentistry) is charged with interpreting and implementing these state regulations.
Delegation and Supervision of Auxiliaries
Expanded Functions: These are specific intraoral functions delegated to qualified dental auxiliaries who possess additional skills and training. A dentist may only delegate these if they are explicitly included in the State Dental Practice Act.
Doctrine of Respondeat Superior: Translated as "let the master answer," this doctrine means the employer is responsible for any harm caused by the actions of an employee while the employee is carrying out the employer's business.
In dentistry, a patient may sue the dentist for an error committed by a dental assistant or hygienist.
Notably, the employee is also responsible for their own actions; an injured patient may file suit against the dental assistant personally as well.
Patient of Record: Defined as an individual who has been examined and diagnosed by a licensed dentist, and for whom a treatment plan has been established by that dentist.
Levels of Supervision:
Direct Supervision: The dentist has delegated a specific procedure to a legally qualified auxiliary for a patient of record. The dentist must examine the patient before delegating and again after the procedure is finished. The dentist must be physically present in the office during the procedure.
General Supervision: The dentist has authorized and delegated specific procedures for a patient of record, but need not be physically present in the office. Common examples include exposing radiographs and recementing a dislodged temporary crown.
Unlicensed Practice of Dentistry: Performing procedures not legal under the State Dental Practice Act constitutes practicing without a license, which is a criminal act. Ignorance of the law is not a valid excuse. Following a dentist's request to perform an illegal expanded function remains a criminal act for the assistant.
Standards of Care and Legal Liabilities
Standard of Care: The level of care at which an average provider with similar training and experience would practice in the same or similar locality. Providers have a legal duty of "due care."
Abandonment: The discontinuation of care after treatment has started but before it is completed.
A dentist cannot legally refuse to give a patient another appointment even if the patient is non-compliant with instructions or missed appointments.
Dismissing a patient of record requires written notice of termination and allowing sufficient time for the patient to secure a new dentist.
Patient Responsibilities: Patients are legally required to pay agreed-on fees for services and are expected to cooperate and follow all treatment and home care instructions.
Malpractice (The Four D’s): All four conditions must be present for a lawsuit to succeed:
Duty: A dentist-patient relationship must be established.
Dereliction: Negligence occurred because the standard of care was not met.
Direct Cause: The negligent act was the individual cause of the injury.
Damages: Includes pain, suffering, loss of income, and medical bills.
Types of Malpractice:
Act of Omission: Failure to perform an act that a "reasonable and prudent professional" would perform (e.g., failing to diagnose periodontal disease due to lack of x-rays or probing).
Act of Commission: Performing an act that a "reasonable and prudent professional" would not perform (e.g., administering 15 cartridges of local anesthetic to a small child, resulting in a fatal overdose).
Res Ipsa Loquitur: Meaning "the thing speaks for itself." This applies when the evidence is clear, such as extracting the wrong tooth or leaving a broken instrument piece inside a tooth.
Risk Management and Prevention
Strategies for Lawsuit Prevention:
Excellent communication and maintaining a good rapport with patients.
Maintaining accurate and complete patient records.
Obtaining proper informed consent.
Maintaining the highest standards of clinical excellence.
Lawsuit Avoidance: Patients are less likely to sue if they understand the planned treatment, expected results, potential complications, and financial obligations.
"Silence is Golden": Dental assistants must never criticize treatment rendered by their employer or any other dentist. Spontaneous statements made at the time of an alleged negligent act are admissible as evidence in court.
Informed Consent Procedures
Types of Consent:
Implied Consent: Given when a patient agrees to treatment or does not object. It is less reliable in court.
Written Consent: The preferred method for documenting understanding and agreement.
Required Explanations for Informed Consent:
The nature of the proposed treatment.
Benefits and consequences of not undergoing treatment.
Common and severe risks associated with the treatment.
Reasonable alternatives, including their respective risks and benefits.
Informed Refusal: If treatment is refused, the dentist must inform the patient of likely consequences and document the refusal. This does not release the dentist from providing the standard of care; they cannot ethically or legally provide substandard care even if the patient consents to it.
Consent for Minors: Must be given by a parent, custodial parent, or legal guardian. For separated parents, the custodial parent's information should be on file; for shared custody, consent letters from both are recommended.
Documentation Requirements: Records should always indicate that risks and benefits were discussed. Written consent is highly recommended for situational risks (new drugs, experimentation, photographs, treatment exceeding one year, or public programs for minors). The form should be signed by the patient, dentist, and a witness, with the original kept in the chart.
Patient Referrals and Attendance Documentation
Referrals: Dentists must refer cases beyond their scope of training to specialists and document this thoroughly. Failure to refer (e.g., failing to send a patient with periodontal disease to a periodontist) is a common cause of malpractice claims.
Guarantees: No outcomes can be completely predicted. Staff must never make claims that could be interpreted as a guarantee.
Contributory Negligence: Broken or canceled appointments and decisions to discontinue treatment must be noted. This documentation protects the practice if the patient later claims negligence, as it proves the patient's own actions contributed to the outcome.
Management of Patient Records
Ownership: The dentist technically owns all patient records and radiographs.
Patient Rights: Patients have the right to access (review) and retrieve (remove/copy) their records. However, original records and radiographs must never leave the practice without the dentist's permission.
Contents: All exams, diagnoses, x-rays, consent forms, medical histories, prescriptions, and correspondence are filed together as legal documents.
Abuse and Neglect Reporting
Legal Protections and Mandates: Many states mandate dental personnel to report suspected child abuse. Mandated reporters are granted Immunity from criminal or civil liability for reporting suspicions.
Classifications of Abuse:
Child Abuse: Acts of omission or commission endangering physical/emotional health (physical abuse, emotional deprivation, sexual exploitation, physical neglect).
Domestic Violence: Battering or control over an intimate individual in the same household.
Elder Abuse: Abuse of an elderly patient by a relative or healthcare provider; signs include physical injury or being withdrawn.
Dental Neglect: Willful failure by a guardian to seek treatment for caries and infection. Signs include rampant caries detectable by a layperson, chronic pain, or difficulty with daily school/play activities.
Health Insurance Portability and Accountability Act (HIPAA)
Objectives:
Provide consumers greater access to healthcare insurance.
Protect the privacy of protected health information.
Promote standardization and enhance efficiency in the healthcare industry.
Compliance: All dental health professionals must strictly adhere to HIPAA regulations.