Common Ethical Problems and Dilemmas

How common are ethical dilemmas in dentistry? That is a very difficult question to answer as the perception and awareness of ethical issues varies with the individuals involved. No studies or evidence exists documenting the volume of problems. However, Boards of Dentistry often cite ethics as causative in cases considered by these agencies. Each situation involving human beings will be unique since each problem or dilemma will have distinguishing aspects. The following listing provides the general categories that have been acknowledged as ethical dilemmas in the dental ethics literature.8,10,11

Categories of Ethical Dilemmas

  • Breaches of confidentiality
  • Failure to disclose dental mistakes
  • Over treatment and poor quality dental treatment
  • Requests for fraudulent documentation
  • Requests for narcotic medications
  • Requests for inappropriate treatment
  • Deceptive dental marketing and advertisements
  • Impaired or dishonest colleagues
  • Challenges with capacity and informed consent
  • Conflict or unethical behavior among clinicians
  • Challenges arising from management, finance or legal issues

The scope and depth of ethical problems in the delivery of dental care will vary greatly. Discerning or being aware that an ethical issue is present is always the first step followed by defining the aspects of the problem. Every clinical situation has ethical aspects.

Application of Decision-making Model in a Hypothetical Case

You are a new clinician in an established dental clinic in a large urban area that sees patients from many different immigrant groups. To accommodate these patients and facilitate treatment, the practice employs several interpreters and dental assistants from these various communities.

One day, the interpreter for a new family comes to you concerned about the three children whom she is interviewing for your next screening appointments that afternoon. The family was referred from a local church which has been helping a number of immigrant families in the community. The children seem healthy, well-adjusted and pleasant but have obvious serious dental problems. The oldest child, nine year old Angie has anterior decay across all her maxillary teeth and the youngest, three year old Sophie has only black stubs for teeth.

The mother is pleasant and very caring for her children. She invites you to their church for a special festival -- a feast and a dance to celebrate the end of the harvest. She talks about what she would like to cook for you and the nice people in the office. The interpreter tells you that you should inform child protective services (CPS) because of this high level of neglect. After your examination of the three children, you too are very concerned about the level of dental disease you have observed as they fit the definition of dental neglect in your state.

Applying the Ethical Decision-making Model

Step 1. What is the ethical question?

Should the clinician report to child protective services the dental neglect found in the children? Is this dental neglect or dental ignorance? What is the responsibility of the clinician in this case to the children and the parent?

Step 2. Collect information

Determine the history of the family and the length of time they have been in the US --- they are from a small country in Eastern Europe and have been in the US six months.

The dental practice appears to have a relationship with the local church, what guidance do they provide for these folks and do they cover the cost of care --- a clerk at the church helps set up appointments and the church pays for basic care. The children are healthy, happy and well-adjusted --- Mom is involved, cooks and cares for them and is present in the dental office.

The interpreter and the clinician have observed that dental disease is present and meets the definition of neglect – what would the likely course of action be from child protective services for these children based on history and information. CPS workers usually take one to two weeks to respond on non-emergency issues, according to the website.

Step 3. State the options

  1. Treat the children.
  2. Call child care services and report the cases of dental neglect in these two children.
  3. Call child care services for information and guidance.
  4. Wait until the children can been seen for treatment; monitoring their return visits to assure that dental care is provided in a timely manner.
  5. Begin education with the mother about dental disease and prevention.

Step 4. Apply the principles

  1. Treat the children if and when they present for treatment would be acknowledging the autonomy of the parent to choose for her minor children.
  2. Call child care services and report the cases of dental neglect in these two children.
    This option would be honoring the principle of nonmaleficence, removing harm as dental disease is harmful and veracity as it would also meet the legal statute of the state for reporting negligence.
  3. Call child care services for information and guidance.
    This option would be honoring the principles of beneficence, determining how to restore oral health to these children, especially if basic costs are exceeded. It could also meet the intent of the legal statute.
  4. Wait until the children can been seen for treatment; monitoring their return visits to assure that dental care is provided in a timely manner.
    This option would be honoring the principles of autonomy, respecting the mother’s understanding and choice for care for her children.
  5. Begin education with the mother about dental disease and prevention.
    This option would honor beneficence, educating the mother and children about oral health. It would also acknowledge justice, as this was new information to the mother having come from a culture that did not understand or possibly value oral health.

Step 5. Make the decision

#4 is the first option chosen in this situation because the children are in the dental office and all indications are that the Mom will proceed with treatment. Informing CPS would most likely not get dental care any faster for these children. Option #5 would be also be part of the treatment plan.

Step 6. Implement the decision

Provide dental treatment to the children.

In this hypothetical case, additional options might be available. Often discussing a case like this among colleagues would result in additional thoughts, suggestions and options. The model is diagramed in a circle as information can change requiring the clinician to reframe the initial question and begin again based on new facts.