Ethical dilemmas among dental professionals in Davangere city– a cross-sectional survey
Priyanka SG, Hitashi Singla, Denzy Lawrence, Veeresh DJ
To determine the ethical problems faced by dental practitioners, a cross-sectional survey was conducted in Bapuji Dental College and Hospital, College of Dental Sciences and private dental clinics in the city of Davangere. A questionnaire with close-ended questions on eight scenarios was administered to the 135 study participants. In the case of scenario 1, 81.4% of the participants said that the doctor had violated the principle of truthfulness. As for scenario 2, less than 50% of the participants replied that the doctor had breached ethical principles. In case scenario 3, 93% felt that the doctor should have taken the physician’s opinion before extracting a tooth. Most dental practitioners faced ethical dilemmas because of the lack of awareness, and there is a need to introduce certain programmes to promote knowledge of ethics.
The word “ethics” is derived from the Greek word “ethos”, which means character or conduct (1). It is usually used interchangeably with the word “moral”. “Moral” is derived from the Latin word “mores”, which means customs or habits. Ethics refers to the conduct, character and motivations involved in moral acts. Ethics is not imposed by a profession or by law, but by moral obligation. It is an unwritten code of conduct that encompasses both professional conduct and judgement. Ethics helps to support autonomy and self-determination and to protect the vulnerable, and promotes the welfare and equality of human beings. An ethical dentist–patient relationship is based on trust, honesty, confidentiality, privacy and the quality of care (2).
The ethical issues faced by dentists in today’s society have become more complex than earlier and seem to arise more often than those faced by dentists in the past (3). Dentists have a dual role, being at the same time health professionals and individuals running a business enterprise. In each role, they are confronted with specific and conflicting ethical demands (4). Dental professionals today often encounter ethical dilemmas, as taking a decision on the best dental treatment has become more a matter of respecting the decision of the patient than professional paternalism.
A dilemma is a complex situation necessitating a choice between two equally undesirable alternatives. “Dilemma” is a word reserved for some of the hardest issues in ethics. Ethical dilemmas arise from fundamental conflicts among ethical beliefs, duties, principles and theories (5). An ethical dilemma is “an apparent mental conflict between moral imperatives, which means obeying one would result in transgressing another. An ethical dilemma is also called an ethical paradox because in moral philosophy paradox often plays a central role in debates on ethics” (4, 6). The topics of ethics, integrity, compromise and corruption have to become as important as the other critical areas of law enforcement training if significant changes are to occur (7). Ethical dilemmas will be a part of the science of dentistry, as in this field one comes across situations with varied ethical considerations and complexities. (3).
Clinical ethical perspectives are important and can be used to educate future dentists as well as professionals in healthcare, and to continually improve overall health operations. To improve decision-making in healthcare, there is a need to address ethical concerns because of the growing use of high technology and the great complexity of our healthcare systems (8, 9, 10, 11). Dental ethics involves the moral duties and obligations of dentists towards their patients, professional colleagues and society (12). These ethical values help to support autonomy and self-determination, protect the vulnerable, and promote the welfare and equality of human beings (13, 14, 15).There is a need to assess the ethical dilemmas faced by dental professionals in the Indian context. Hence, this study was conducted with the aim of determining the ethical problems encountered by dental practitioners and the difficulties faced by them in solving these problems in their practice.
Materials and methods
A cross-sectional survey was conducted in Bapuji Dental College and Hospital, Davangere, College of Dental Sciences, Davangere, and private dental clinics, Davangere, by a group of 16 undergraduate students from January to April 2014.
The survey was conducted after ethical clearance was obtained from the institutional review board of Bapuji Dental College and Hospital. It covered the faculty members, practitioners of Davangere, and postgraduate students of both dental colleges. A detailed list of dentists in the city of Davangere was obtained from the Indian Dental Association branch of Davangere. After explaining the purpose of the study and obtaining voluntary informed consent, a self-administered, self-designed questionnaire containing seven scenarios (Table 1) was given to the study participants. A total of 135 subjects agreed to participate in the study. The postgraduate students and faculty members who were involved in the survey were dropped from the sample so as to eliminate bias. The questionnaire was designed by the investigators and contained closeended questions. Table 1 contains the seven scenarios and the accompanying questions.
|Table 1: Scenarios 1-7|
1. Raju, a nine-year-old, went for his first dental check-up. He had an unsalvageable mandibular first molar that was causing him serious pain and the doctor planned to extract it. Raju was apprehensive and asked the doctor what he was going to do. The doctor did not want to upset the child and said, “I am just going to look into your mouth.”
2. A 65-year-old man with a history of cardiac problems was referred to an oral surgeon for the extraction of a badly decayed first molar. The adjacent second molar, too, had a large carious lesion but was restorable. The patient requested the surgeon to extract both teeth and also, to prescribe antibiotics. The surgeon knew that antibiotics were not at all necessary and also that unnecessary extractions would complicate the case. Considering these facts, the doctor decided to extract only the first molar.
3. Mr Kumar went to Dr Umesh with a complaint of tooth mobility. He disclosed that he was a haemophiliac, but did not know the consequences of this. The doctor knew the consequences and without taking a physician’s opinion, went ahead and extracted the tooth, which had grade III mobility.
Yes – 93%
4. A private dental practitioner, Dr Praveen was a dentist of repute and many patients visited his clinic even from distant villages. One day, a friend of his visited his clinic for treatment. Many patients had been waiting to see Dr Praveen for a long time, but his friend entered his chamber first.?
Yes – 7.0%
5. Mr Satish visited Dr Sharma’s clinic with the complaint that there was a persistent white patch on his tongue that could be removed by scraping. Mr Satish visited the dentist quite frequently for his oral healthcare requirements, which included scaling and fillings. Following systemic investigations, Dr Sharma discovered that Mr Satish was HIV-positive. He did not reveal this to his patient. He sent the patient away, denying him further treatment.
6. Mr Anmol, who was 58 years old, visited a private dental clinic for the removal of several teeth. Dr Alok learned through his routine investigations that Mr Anmol was diabetic and hypertensive. He went ahead and extracted several teeth without informing the patient about his systemic conditions or prescribing any medication for these.
7. Ms Smitha regularly visited a dentist in her neighbourhood for all her oral health care needs. She went to see him when she developed pain in a certain tooth, for which she had undergone restoration a few weeks earlier. However, her dentist was on leave so she went to another dentist. When the new dentist examined the tooth, he discovered overhanging margins with chronic periodontal involvement.
The questionnaire was divided into two parts. The first part was meant to gather socio-demographic information on the participants, such as their level of education, the institute and department to which they belonged, and the duration of their practice. The second part included a set of questions to assess the participants’ knowledge of ethics and its application in their day-to-day practice. It consisted of a set of seven scenarios with close-ended questions meant to evaluate the various ethical conflicts faced by them. Each participant was given 15 minutes to complete the questionnaire, after which it was collected by the investigators.
The study was conducted to understand the ethical dilemmas faced by dentists while making decisions in their clinical practice. Of the 135 participants, 45 were postgraduate students in the final year and 90 were faculty members who had been practising for at least 10 years. In the case of scenario 1, 81.4% of the participants were of the opinion that the doctor had violated the principle of truthfulness. As for scenario 2, 39.5%, 30.2%and 27.9% of the participants felt that the doctor had breached the principles of beneficence, justice and autonomy, respectively. According to 14%, the doctor should have gone ahead with the extraction of both teeth, while 79.1% thought he should not have, and 4.7% were not able to decide.
In the case of the third scenario, 93% of the participants felt that Dr Umesh should have taken a physician’s opinion before extracting the tooth and 4.7% thought he should not have. In all, 83.7%, 9.3% and 4.7% of the participants were of the view that by not taking a physician’s opinion, the doctor had violated the principle of non-maleficence, truthfulness and autonomy, respectively.
In the case of the fourth scenario, 7% of the respondents agreed that Dr Praveen was right in giving his friend priority over the other patients waiting in line. According to 22.3%, 4.7% and 69.8% of the participants, Dr Praveen had breached the principle of beneficence, confidentiality and justice, respectively.
As for the fifth scenario, 25.6% of the participants felt that a dentist should explain the details of systemic investigations if the patient insists, otherwise he should remain silent. According to 62.8% of the respondents, there was no need to explain, while 9.3% were undecided. According to the 27.9%, Dr Sharma should have informed Satish’s relatives about his illness and not Satish himself; 58.1% did not agree with this; and 11.6% were undecided.
In the case of the sixth scenario, 14% of the participants thought that Dr Alok was right in extracting the teeth, whereas 83.7% did not agree that the teeth should have been extracted without informing the patient about the other treatment options. According to 83.7% of the respondents, the patient should have been informed about his systemic illnesses, whereas 14% were of the opposite view.
Regarding the seventh scenario, 2.3% of the participants felt that the new dentist should have informed the patient about the maltreatment by the previous dentist, 5.2% were in favour of re-contouring the overhanging restoration without informing the patient, and 44.2% felt that the dentist should discuss the matter with the patient and the previous dentist.
The day-to-day decisions made by dental professionals have a significant influence on the oral health of the population. Contemporary codes of practice direct dentists to provide patients with all the necessary information and to offer them guidance so that they can select the appropriate treatment. This study was conducted to assess the ethical dilemmas encountered by practising dentists to get an idea of the difficulties faced by them in treating their patients.
A clinician’s failure to provide the patient with pertinent information has ethical and potentially legal implications. This is why informed consent is important (11, 12). In scenario 1, more than half the participants felt that if the dentist does not inform the apprehensive and uncooperative patient about the treatment he/she is going to give him, then he/she is not being truthful to the patient. The rest of the respondents felt that to do good to the patient, it is better not to inform him. The first scenario created a conflict between the principles of truthfulness and beneficence. So to do good, the dentist has to tell a lie and to avoid being a liar, he/she cannot provide the treatment. In both cases, the dentist will be acting unethically. To overcome the dilemma, it is better to decide the breaching of which principle will provide more benefit to the patient. In scenario 5, more than half the participants responded that the patient should be informed about his illness as it is the dentist’s duty to inform the patient before he/she either refuses to provide the treatment or provides the treatment. Since the disease is transmissible, the dentist should inform the patient but not his relatives as this will breach confidentiality. Whether or not to inform the patient or his relatives about a disease which is fatal is an ethical dilemma. In terms of assuring appropriate information provision to the patient, the concept of minimal risk will be useful to solve the problem of providing valid information to the patient. (3, 4).
Though acting according to the patient’s wish comprises autonomy, sometimes patients are not aware of the good and bad outcomes of the treatment, so the doctor or dentist should inform them about these and guide them to take an appropriate decision. In the third scenario, the doctor has blindly provided the treatment sought by the patient without informing him about its consequences. Is it right to say that he has followed the principle of autonomy by not informing the patient about the pros and cons of the treatment being sought? Is it not unethical that to follow one principle, he has breached two principles, ie non-maleficence and beneficence?
As the dental profession is more like a business, the competitiveness in the profession can influence negativeness. In scenario 7, the practising dentist faces the problem of deciding on the right option in treating a maltreated patient. Most dentists do not like to denigrate their colleagues.
Earlier, doctors and dentists had a paternalistic approach when deciding on the treatment of their patients, ie their approach was akin to that of a parent. Today, the scenario has changed. It is the patient who decides on how his ailment is to be treated. However, patients do not have complete information on different treatment modalities, so they are often unable to decide on the best treatment option. In scenario 2, most participants could not reach a consensus on whether the dentist should follow the patient’s demand regarding the treatment, which would mean abiding by the first ethical principle of autonomy, or to follow their clinical expertise to make a decision on the treatment, which would mean abiding by the principles of beneficence and non-maleficence. In the case of this scenario, there was confusion about whether to follow the principle of autonomy and opt for patient-centred care or to follow the paternalistic approach by favouring beneficence and non-maleficence.
In the dental profession, it is difficult at times to decide which principle to follow. Ethical principles are meant to guide the healthcare provider with the aim of serving humanity. As there is a hairline difference between the various principles, following one can mean violating another. This results in moral distress, which has been defined as knowing the ethically correct thing to do but feeling unable to act (13, 14, 15). Indeed, research suggests that acting against one’s conscience at work can have a number of serious consequences for individuals and organisations. The consequences include: (i) compassion fatigue and burnout among healthcare personnel; (ii) decrease in an individual’s level of empathy, and avoiding or withdrawing from patients; (iii) decreased quality of service in terms of patients’ safety, patients’ experience and effectiveness of care; and (iv) deterioration in the general health and wellbeing of staff, with high staff turnover rates and staff shortages (12).
A limitation of this study is that the questionnaire used was checked for face validity but not reliability. Also, the study suffered from social desirability bias.
The survey explores the ethical dilemmas encountered by dentists in Davangere. The responses of the dentists regarding how to deal with ethical dilemmas were most varied. Ethical dilemmas are faced by most dental practitioners, though the majority of them are unaware of the ethical principles.
Considering the lack of awareness of the ethical principles among the majority of dental practitioners, certain programmes and events should be conducted to promote knowledge of ethics.It is imperative that dental practitioners be given a primer course in ethics to help build their professional communication skills, and to promote personal as well as patient safety measures.
- Meese E, III, Ortmeier PJ, editors. Leadership, ethics, and policing: challenges for the 21st century. 2nd ed. Prentice Hall; 2009:61-83 [cited 2015 Mar 22]. Available from: http://wps.pearsoncustom.com/wps/media/objects/4172/4272973/CJ401_Ch04.pdf
- Davis R, Roberts LW. Ethics conflicts in rural communities: patient provider relationship. In: Nelson WA, editor. Handbook for rural health care ethics: a practical guide for professionals. New England: University Press; 2009:82-107 [cited 2014 Jan18]. Available from: https://geiselmed.dartmouth.edu/cfm/resources/ethics/chapter-05.pdf
- Ozar DT, Sokol DJ. Dental ethics at chairside: professional principles and practical applications. 2nd ed. Washington, DC: Georgetown University Press; 2002.
- Beemsterboer P. Ethics and law in dental hygiene. 2nd ed. St Louis, MO: Saunders Elsevier; 2010.
- Mitchell C. Ethical dilemmas. Crit Care Nurs Clin North Am. 1990;2(3):427-30.
- Porter SA, Grey WL. Ethical dilemma/not able to decide confronting dentists in Queensland, Australia. Aust Dent J. 2002;47(3):241-8.
- Welie JV. Is dentistry a profession? Part 1. Professionalism defined. J Can DenAssoc. 2004;70(8):529-32.
- Hunink M, Glasziou P, Siegel J, Weeks J, Pliskin J, Elstein A, Weinstein M. Decision making in health and medicine: integrating evidence and values. UK: Cambridge University Press; 2001.
- Sox HC, Blatt MA, Higgins MC, Marton KI, (eds). Medical decision making. Newton, MA: Butterworth Heinemann; 1988.
- Huff K, Huff M, Farah C. Ethical decision-making for multiple prescription dentistry. Gen Dent. 2008;56(6):538-47.
- Acharya S. The ethical climate in academic dentistry in India: faculty and student perceptions. J Dent Educ. 2005;69(6):671-80.
- Sharp HM, Kuthy RA, Heller KE. Ethical dilemmareported by fourth-year dental students. J Dent Educ. 2005;69(10):1116-22.
- Appelbaum PS, Berg JW, Lidz CW, Parker LS. Informed consent: legal theory and clinical practice. 2nd ed. New York: Oxford University Press, 2001.
- Moayyeri A, Soltani A, Moosapour H, Raza M. Evidence-based history taking under “time constraint”. J Res Med Sci. 2011;16(4):559-64
- Jameton A. Nursing practice: the ethical issues. New York: Prentice Hall; 1984.