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Ethics and Dental Amalgam Removal
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ETHICS AND DENTAL AMALGAM REMOVAL
JOHN G. ODOM, PH.D.
^ n late 1990, millions of Americans sat transfixed before their television sets as a highly rated “news magazine” implied that toxic matter in dental amalgam restorations can cause or exacerbate serious illness. As a result, patients have bombarded dentists with questions about amalgam restorations and requests for amalgam removal. What ethical principles provide guidance as the dental profession formulates responses to the questions patients are raising about mercury amalgam removal? This paper identifies the funda mental ethical issues and ethical principles directly related to questions of amalgam removal. When examining the ethics of amalgam removal, the chief issue is who initiates the removal of dental amalgam—the dentist or the patient. DENTIST-INITIATED REMOVAL
Based on the current scientific evidence, there is no justification for a dental practitioner to initiate the removal and replacement of dental amalgam with other materials.16This is true even if the dentist genuinely believes that dental amalgam restorations are dangerous and that their removal is in the patient’s best interest. Scientific evidence simply does not support amalgam removal. ADA Resolution 42H-1986
Recent media attention regarding dental amalgam restorations has generated needless fears among millions o f dental patients. This article examines the issue o f dental amalgam removal from an ethical perspective and offers some practical advice on how to address this problem in the dental office. defines the conditions under which amalgam removal is clearly unethical. This Advisory Opinion to the ADA “Principles of Ethics and Code of Professional Conduct” states that: ...the removal of amalgam restorations from the nonallergic patient for the alleged purpose of removing toxic substances from the body, when such treatm ent is performed solely at the recommen dation of the dentist, is improper and unethical.... A dentist who represents that dental treatm ent recommended or performed by the dentist has the capacity to cure or alleviate diseases, infections or other
conditions, when such representations are not based upon accepted scientific knowledge or research, is acting unethically.7 The key phrase in this opinion is “solely at the recommendation of the dentist.” Without supporting scientific evidence to justify amalgam removal, a dentist who initiates amalgam removal violates the ethical principle of beneficence. Beneficence is the obligation to provide service and benefits to others, the concept of “doing good” for the patient. The relationship between beneficence and profes sionalism is well documented in dental literature.811McCullough’s12 presentation of the beneficence model of moral responsibility in dentistry addresses the impor tance of a body of knowledge and skills that form the basis of beneficent treatment. He asserts that, over the years, dentistry has amassed wisdom about what interventions will and will not contribute to the protection and promotion of oral health. McCullough further explains that beneficent treatm ent is not idiosyncratic and something left for each dentist to determine on the basis of individual values and
JADA, Vol. 122, Ju n e 1991
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beliefs. By sharing common values that are objectively derived, dentistry is permitted “to speak of quackery and profiteering and, rightly, to condemn them.”12 Thus, the principle of beneficence can be applied to questions of amalgam removal. The dentist who initiates removal in the absence of an allergic reaction to amalgam, with or without a genuine belief that the amalgam may be harmful, is violating the obligation to provide beneficent treatment. The dentist who initiates removal based on a genuine belief that amalgam restorations are harmful is behaving idiosyncratically and violating collective professional standards of beneficent treatment. The dentist who initiates removal for personal benefit deserves condemnation for profiteering and disregard for the duty to benefit the patient.
based on reactions to recent publicity about dental amalgams, the dentist’s first priority should be patient education. The dentist should reassure the patient that current scientific evidence does not support amalgam removal. Furthermore, the dentist should present the potential harms associated with amalgam removal. For example, the high degree of concentrated vapor release that
PATIENT-INITIATED REMOVAL
If it is unethical for a dentist to initiate amalgam removal, can the dentist ethically remove amalgam restorations at the patient’s request? Two fundamental ethical principles—nonmaleficence and autonomy—offer guidance to the dentist when making a decision regarding a patient’s request. Nonmaleficence. Nonmale ficence is based on the Hippocratic tradition and requires the health care provider to “first do no harm.” If the patient is experiencing no difficulty and has made a request
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occurs during removal may be more dangerous than leaving dental amalgam in place, and its removal cannot be accomplished without damaging the integrity of tooth structure. In addition, removing current amalgam restorations may damage the tooth and require a larger, more extensive replacement. Mary Logan, ADA assistant
executive director for the Division of Legal Affairs, has suggested the following steps when discussing patient requests for amalgam removal: ■■ Explain the science (and lack thereof) to the patient; ■" Explain to the patient any potential risk of damaging tooth structure if the amalgam is removed; ™ Discuss the cost of removal and the advantages and disad vantages of replacement materials; ™ Encourage the patient to consult with his/her physician before making a final decision; physician consultation is particularly critical if the patient believes that removal will improve a medical condition such as multiple sclerosis or arthritis.13 The December 1990 ADA Special Report on Dental Amalgam14lists these four steps and continues with the opinion that, given that the patient has a complete understanding of the points covered in the previous disclosure and, if applicable, has obtained a medical consultation, the dentist can ethically choose either to remove the amalgam or refuse to remove the amalgam. Autonomy. Autonomy is based on respect for persons and recog nizes the patient’s right to make decisions regarding his or her own health care. Patients have the right to self-determination and can
Dr. Odom is associate professor, Section of Community Dentistry» The Ohio State University College of Dentistry, Room 3148 Postle Hall, 305 W. 12th Ave., Columbus, Ohio 43210. Address requests for reprints to the author.
select the type of health care they wish to receive. Applying the principle of autonomy to modern dentistry means that the practi tioner must allow patients to participate in an informed consent process before making treatment
decisions. Based on a synthesis of the work of several prominent ethicists, five factors are necessary for an ethically sound informed consent: information, patient comprehension, voluntary deci sion making (no coercion or undue influence), patient competence, and a clearly designated patient decision either to proceed with or refuse a particular treatment. The process of obtaining a valid informed consent requires patient education, well-developed com munication skills and time. Pre senting information in language the patient will understand, answering questions and vali dating patient comprehension of treatment consequences are necessary to obtain valid informed consent. Documentation of the informed consent process, as well as the patient’s decision, is highly recommended. Autonomy is not limited to the patient. Dentists also have the
right to exercise professional autonomy. It has been noted that relinquishing the paternalistic role does not mean the dentist must surrender autonomy in the process of making treatment decisions. “The practitioner still retains the autonomy: 1) to present and explain only those treatment options he/she deems acceptable for meeting patient needs, and 2) to refuse to provide treatment he/she judges as unacceptable.”15 If a dentist determines that a particular amalgam removal would not violate the principle of nonmaleficence (“do no harm”), the dentist has two options regard ing patient-initiated requests for amalgam removal. The dentist may either institute the process of informed consent, incorporating the information outlined as essential by the ADA, or may refuse to proceed with the removal of dental amalgam. SUMMARY
The recent controversy regarding dental amalgam restorations illus trates the impact of societal forces on professional conduct and decision making. Technology, consumerism and the media are having significant impact on the
way professionals provide service. Dentistry’s response to the media’s allegations regarding mercury amalgams has been admirable. The response has been based on scientific evidence and ethical principles and has provided the opportunity to reaffirm and define dentistry’s commitment to profes sionalism and ethical behavior. ■ 1. Reinhardt JW, et al. Exhaled mercury following removal and insertion of amalgam restorations. J Prosthet Dent 1983;49:652-6. 2. Okabe T. Mercury in the structure of dental amalgam. Dent Mater 1987;3:1-8. 3. Enwonwu CO. Potential health hazard of use of mercury in dentistry: critical review of the literature. Environ Res 1987;42:257-74. 4. Mackert JR. Factors affecting estimation of dental amalgam mercury exposure from measurements of mercury vapor levels in intra-oral and expired air. J Dent Res 1987;66:1775-80. 5. Snapp KR, Boyer DB, Peterson LC, Svare CW. The contribution of dental amalgam to mercury in blood. J Dent Res 1989;68:780-5. 6. Berglund A. Estimation by a 24-hour study of the daily dose of intra-oral mercury vapor inhaled after release from dental amalgam. J Dent Res 1990;69:1646-51. 7. American Dental Association. Resolution 42H-1986. Transl986:536. 8. Nash DA. The ethics of profession in dental medicine. Health Matrix 1984;2:3-15. 9. Odom JG. Recognizing and resolving ethical dilemmas in dentistry. Med Law 1985;4:543-49. 10. Pellegrino ED, Thomasma DC. For the patient’s good: the restoration of beneficence in health care. New York: Oxford University Press; 1988. 11. Hasegawa TK, et al. Ethical or legal perceptions by dental practitioners. JADA 1988;116:354-60. 12. McCullough LB. Ethics in dental medicine; a framework for moral responsibility in dental practice. J Dent Ed 1985;49:219-24. 13. Is it ethical to remove? ADA News 1991; Jan 7:5. 14. ADA Special Report. Ethical considerations on removal of dental amalgam. American Dental Association Division of Legal Affairs, December 1990. 15. Odom JG, Morris WO. The autonomy of the practitioner. J Dent Prac Admin 1989;6:12-5.
JADA, Vol. 122, Ju n e 1991
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ETHICS AND DENTAL AMALGAM REMOVAL
JOHN G. ODOM, PH.D.
^ n late 1990, millions of Americans sat transfixed before their television sets as a highly rated “news magazine” implied that toxic matter in dental amalgam restorations can cause or exacerbate serious illness. As a result, patients have bombarded dentists with questions about amalgam restorations and requests for amalgam removal. What ethical principles provide guidance as the dental profession formulates responses to the questions patients are raising about mercury amalgam removal? This paper identifies the funda mental ethical issues and ethical principles directly related to questions of amalgam removal. When examining the ethics of amalgam removal, the chief issue is who initiates the removal of dental amalgam—the dentist or the patient. DENTIST-INITIATED REMOVAL
Based on the current scientific evidence, there is no justification for a dental practitioner to initiate the removal and replacement of dental amalgam with other materials.16This is true even if the dentist genuinely believes that dental amalgam restorations are dangerous and that their removal is in the patient’s best interest. Scientific evidence simply does not support amalgam removal. ADA Resolution 42H-1986
Recent media attention regarding dental amalgam restorations has generated needless fears among millions o f dental patients. This article examines the issue o f dental amalgam removal from an ethical perspective and offers some practical advice on how to address this problem in the dental office. defines the conditions under which amalgam removal is clearly unethical. This Advisory Opinion to the ADA “Principles of Ethics and Code of Professional Conduct” states that: ...the removal of amalgam restorations from the nonallergic patient for the alleged purpose of removing toxic substances from the body, when such treatm ent is performed solely at the recommen dation of the dentist, is improper and unethical.... A dentist who represents that dental treatm ent recommended or performed by the dentist has the capacity to cure or alleviate diseases, infections or other
conditions, when such representations are not based upon accepted scientific knowledge or research, is acting unethically.7 The key phrase in this opinion is “solely at the recommendation of the dentist.” Without supporting scientific evidence to justify amalgam removal, a dentist who initiates amalgam removal violates the ethical principle of beneficence. Beneficence is the obligation to provide service and benefits to others, the concept of “doing good” for the patient. The relationship between beneficence and profes sionalism is well documented in dental literature.811McCullough’s12 presentation of the beneficence model of moral responsibility in dentistry addresses the impor tance of a body of knowledge and skills that form the basis of beneficent treatment. He asserts that, over the years, dentistry has amassed wisdom about what interventions will and will not contribute to the protection and promotion of oral health. McCullough further explains that beneficent treatm ent is not idiosyncratic and something left for each dentist to determine on the basis of individual values and
JADA, Vol. 122, Ju n e 1991
69
beliefs. By sharing common values that are objectively derived, dentistry is permitted “to speak of quackery and profiteering and, rightly, to condemn them.”12 Thus, the principle of beneficence can be applied to questions of amalgam removal. The dentist who initiates removal in the absence of an allergic reaction to amalgam, with or without a genuine belief that the amalgam may be harmful, is violating the obligation to provide beneficent treatment. The dentist who initiates removal based on a genuine belief that amalgam restorations are harmful is behaving idiosyncratically and violating collective professional standards of beneficent treatment. The dentist who initiates removal for personal benefit deserves condemnation for profiteering and disregard for the duty to benefit the patient.
based on reactions to recent publicity about dental amalgams, the dentist’s first priority should be patient education. The dentist should reassure the patient that current scientific evidence does not support amalgam removal. Furthermore, the dentist should present the potential harms associated with amalgam removal. For example, the high degree of concentrated vapor release that
PATIENT-INITIATED REMOVAL
If it is unethical for a dentist to initiate amalgam removal, can the dentist ethically remove amalgam restorations at the patient’s request? Two fundamental ethical principles—nonmaleficence and autonomy—offer guidance to the dentist when making a decision regarding a patient’s request. Nonmaleficence. Nonmale ficence is based on the Hippocratic tradition and requires the health care provider to “first do no harm.” If the patient is experiencing no difficulty and has made a request
70
JADA, Vol. 122, Ju n e 1991
occurs during removal may be more dangerous than leaving dental amalgam in place, and its removal cannot be accomplished without damaging the integrity of tooth structure. In addition, removing current amalgam restorations may damage the tooth and require a larger, more extensive replacement. Mary Logan, ADA assistant
executive director for the Division of Legal Affairs, has suggested the following steps when discussing patient requests for amalgam removal: ■■ Explain the science (and lack thereof) to the patient; ■" Explain to the patient any potential risk of damaging tooth structure if the amalgam is removed; ™ Discuss the cost of removal and the advantages and disad vantages of replacement materials; ™ Encourage the patient to consult with his/her physician before making a final decision; physician consultation is particularly critical if the patient believes that removal will improve a medical condition such as multiple sclerosis or arthritis.13 The December 1990 ADA Special Report on Dental Amalgam14lists these four steps and continues with the opinion that, given that the patient has a complete understanding of the points covered in the previous disclosure and, if applicable, has obtained a medical consultation, the dentist can ethically choose either to remove the amalgam or refuse to remove the amalgam. Autonomy. Autonomy is based on respect for persons and recog nizes the patient’s right to make decisions regarding his or her own health care. Patients have the right to self-determination and can
Dr. Odom is associate professor, Section of Community Dentistry» The Ohio State University College of Dentistry, Room 3148 Postle Hall, 305 W. 12th Ave., Columbus, Ohio 43210. Address requests for reprints to the author.
select the type of health care they wish to receive. Applying the principle of autonomy to modern dentistry means that the practi tioner must allow patients to participate in an informed consent process before making treatment
decisions. Based on a synthesis of the work of several prominent ethicists, five factors are necessary for an ethically sound informed consent: information, patient comprehension, voluntary deci sion making (no coercion or undue influence), patient competence, and a clearly designated patient decision either to proceed with or refuse a particular treatment. The process of obtaining a valid informed consent requires patient education, well-developed com munication skills and time. Pre senting information in language the patient will understand, answering questions and vali dating patient comprehension of treatment consequences are necessary to obtain valid informed consent. Documentation of the informed consent process, as well as the patient’s decision, is highly recommended. Autonomy is not limited to the patient. Dentists also have the
right to exercise professional autonomy. It has been noted that relinquishing the paternalistic role does not mean the dentist must surrender autonomy in the process of making treatment decisions. “The practitioner still retains the autonomy: 1) to present and explain only those treatment options he/she deems acceptable for meeting patient needs, and 2) to refuse to provide treatment he/she judges as unacceptable.”15 If a dentist determines that a particular amalgam removal would not violate the principle of nonmaleficence (“do no harm”), the dentist has two options regard ing patient-initiated requests for amalgam removal. The dentist may either institute the process of informed consent, incorporating the information outlined as essential by the ADA, or may refuse to proceed with the removal of dental amalgam. SUMMARY
The recent controversy regarding dental amalgam restorations illus trates the impact of societal forces on professional conduct and decision making. Technology, consumerism and the media are having significant impact on the
way professionals provide service. Dentistry’s response to the media’s allegations regarding mercury amalgams has been admirable. The response has been based on scientific evidence and ethical principles and has provided the opportunity to reaffirm and define dentistry’s commitment to profes sionalism and ethical behavior. ■ 1. Reinhardt JW, et al. Exhaled mercury following removal and insertion of amalgam restorations. J Prosthet Dent 1983;49:652-6. 2. Okabe T. Mercury in the structure of dental amalgam. Dent Mater 1987;3:1-8. 3. Enwonwu CO. Potential health hazard of use of mercury in dentistry: critical review of the literature. Environ Res 1987;42:257-74. 4. Mackert JR. Factors affecting estimation of dental amalgam mercury exposure from measurements of mercury vapor levels in intra-oral and expired air. J Dent Res 1987;66:1775-80. 5. Snapp KR, Boyer DB, Peterson LC, Svare CW. The contribution of dental amalgam to mercury in blood. J Dent Res 1989;68:780-5. 6. Berglund A. Estimation by a 24-hour study of the daily dose of intra-oral mercury vapor inhaled after release from dental amalgam. J Dent Res 1990;69:1646-51. 7. American Dental Association. Resolution 42H-1986. Transl986:536. 8. Nash DA. The ethics of profession in dental medicine. Health Matrix 1984;2:3-15. 9. Odom JG. Recognizing and resolving ethical dilemmas in dentistry. Med Law 1985;4:543-49. 10. Pellegrino ED, Thomasma DC. For the patient’s good: the restoration of beneficence in health care. New York: Oxford University Press; 1988. 11. Hasegawa TK, et al. Ethical or legal perceptions by dental practitioners. JADA 1988;116:354-60. 12. McCullough LB. Ethics in dental medicine; a framework for moral responsibility in dental practice. J Dent Ed 1985;49:219-24. 13. Is it ethical to remove? ADA News 1991; Jan 7:5. 14. ADA Special Report. Ethical considerations on removal of dental amalgam. American Dental Association Division of Legal Affairs, December 1990. 15. Odom JG, Morris WO. The autonomy of the practitioner. J Dent Prac Admin 1989;6:12-5.
JADA, Vol. 122, Ju n e 1991
71