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Is it ethical for dentists to treat immediate family members?
FEATURES
ETHICAL MOMENT
Is it ethical for dentists to treat immediate family members? G. Jack Muller II, DDS, MS
Q
I have always provided care to my spouse, our children, and a number of other close relatives. Recently, a physician friend of mine told me that, as a physician, it was not considered ethical to treat members of one’s own family. Now I am wondering—is it ethical for me as a dentist to treat my own family?
A
There certainly are many practitioners who provide dental care for their own family members, and many of us have been cornered by a relative who asks for advice regarding their dental needs. In some circumstances, it can be difficult to know how best to handle these situations and to know whether it is ethical to treat family or even very close friends. In the Code of Medical Ethics of the American Medical Association, Opinion 8.19 states, “Physicians generally should not treat themselves or members of their immediate families.”1 The opinion further warns that professional objectivity may be compromised when treating family members and affect the medical care being given. Other concerns include the possibility of difficulty broaching sensitive topics with family members and physicians being tempted to try treatment beyond their scope of training. Does providing dental care to family members raise the same issues faced by physicians? Outwardly, it may appear that there are parallels,
760 JADA 147(9) http://jada.ada.org
but there are many dentists who see no conflict of interest in providing care to relatives. The American Dental Association Principles of Ethics and Code of Professional Conduct (ADA Code)2 does not have any provisions similar to those in the Code of Medical Ethics of the American Medical Association, so there is no specific prohibition against a dentist treating family members. The American Student Dental Association Ethics Code, Section III, Nonmaleficence and Beneficence, Part E, states, “Students should exercise discretion in treating family members due to problems associated with medical history disclosure, confidentiality, objectivity, and professionalism.”3 Even without a specific prohibition, there are several provisions within the ADA Code that should be taken into consideration in determining whether it is appropriate to provide care to family members. Section 1, Patient Autonomy (“selfgovernance”), states, “The dentist has a duty to respect the patient’s right to self-determination and confidentiality.”2 In the case of children, and especially minor children approaching the age at which they are involved in decision making about their own care, it may be difficult for the dentist to take the patient’s best interests into account if the dentist feels his or her professional judgment is more important than the child’s or relative’s desires. At the same time, a patientrelative may not feel able to refuse a recommendation for treatment for fear of offending his or her dentist-
September 2016
relative. Patient-relatives have the same rights as nonrelative patients, including informed consent and the need to hear all the risks, benefits, side effects, and alternatives to the proposed treatment and to participate in the decision-making process. In caring for a relative, the informed consent dialogue may be minimal or even nonexistent. Consideration of Section 2, Nonmaleficence (“do no harm”), is also critical: “This principle expresses the concept that professionals have a duty to protect the patient from harm.”2 Protection from harm includes knowing our skills and limitations and understanding when to refer a patient to a specialist. With a family member, a dentist may be tempted to provide care beyond his or her expertise or outside his or her training in an effort to make care more convenient or perhaps less costly for the relative. The risk in providing treatment that is below the standard of care is a concern as is the risk of causing actual harm to the patient-relative. Another concern may arise when taking a medical history of a close relative. There may be significant sensitive areas that the patient-relative may not wish to disclose to the dentist-relative or about which the dentist-relative might feel uncomfortable asking, which could result in an adverse outcome of the care being provided. Under Section 3, Beneficence (“do good”), the ADA Code states, “The dentist has a duty to promote the patient’s welfare.”2 It is entirely possible that a dentist’s relationship to the relative is such that the
FEATURES
dentist’s professional judgment may be clouded. Many of us have been encouraged in dental school always to treat our patients like they are family under the assumption that we would want only the best care for our own family members. In reality, we are parents, spouses, brothers, sisters, or in other ways related to our family just like everyone else, and we worry about the effect an experience may have on a relative, not wanting to cause the person pain or disappointment with unsuccessful care or other emotion-based concerns, which may make us less objective about what may be the best for our patientrelative. However, in emergency situations, or in the event no other provider is available, there should be no hesitation in providing whatever appropriate care we can to our family in the interest of their well-being. Researchers have developed a series of questions to ask to aid physicians in determining whether providing nonemergent care to family members is appropriate.4 These questions are adapted easily and appropriately for dental professionals: - Am I trained to address this dental need? - Am I too close to obtain intimate history and to cope with bearing bad news if need be?
Can I be objective enough not to overtreat, undertreat, or give inappropriate treatment? - Is my being dentally involved likely to cause or worsen family conflicts? - Is my relative more likely to comply with an unrelated dentist’s care plan? - Will I permit any dentist to whom I refer a relative to treat that relative? - Am I willing to be accountable to my peers and to the public for this care? If you can consider these questions objectively and answer them satisfactorily to determine that you are competent to provide care to your relative and have no conflict of interest, then from the standpoint of the ADA Code, you are free to provide dental care to your family members. n -
http://dx.doi.org/10.1016/j.adaj.2016.04.014 Copyright ª 2016 American Dental Association. All rights reserved.
Dr. Muller practices oral and maxillofacial surgery in Rapid City, SD, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Address correspondence to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, IL 60611.
Disclosure. Dr. Muller did not report any disclosures. Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, IL 60611, e-mail [email protected] or call the ethics hotline at 1-800-621-8099. The views expressed are those of the author and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA. 1. American Medical Association. Opinion 8.19—self-treatment or treatment of immediate family members. Available at: http://www.amaassn.org/ama/pub/physician-resources/medicalethics/code-medical-ethics/opinion819.page. Accessed January 27, 2016. 2. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. Available at: www.ada.org/sections/about/pdfs/ code_of_ethics_2012.pdf. Accessed January 27, 2016. 3. American Student Dental Association. ASDA ethics code. Available at: http://www. asdanet.org/codeofethics.aspx. Accessed January 27, 2016. 4. Douglas, S. Consider ethics, patient rights before treating your immediate family. American Medical News. April 13, 2009. Available at: http://www.amednews.com/article/20090413/ profession/304139977/5/. Accessed January 27, 2016.
JADA 147(9) http://jada.ada.org
September 2016 761
ETHICAL MOMENT
Is it ethical for dentists to treat immediate family members? G. Jack Muller II, DDS, MS
Q
I have always provided care to my spouse, our children, and a number of other close relatives. Recently, a physician friend of mine told me that, as a physician, it was not considered ethical to treat members of one’s own family. Now I am wondering—is it ethical for me as a dentist to treat my own family?
A
There certainly are many practitioners who provide dental care for their own family members, and many of us have been cornered by a relative who asks for advice regarding their dental needs. In some circumstances, it can be difficult to know how best to handle these situations and to know whether it is ethical to treat family or even very close friends. In the Code of Medical Ethics of the American Medical Association, Opinion 8.19 states, “Physicians generally should not treat themselves or members of their immediate families.”1 The opinion further warns that professional objectivity may be compromised when treating family members and affect the medical care being given. Other concerns include the possibility of difficulty broaching sensitive topics with family members and physicians being tempted to try treatment beyond their scope of training. Does providing dental care to family members raise the same issues faced by physicians? Outwardly, it may appear that there are parallels,
760 JADA 147(9) http://jada.ada.org
but there are many dentists who see no conflict of interest in providing care to relatives. The American Dental Association Principles of Ethics and Code of Professional Conduct (ADA Code)2 does not have any provisions similar to those in the Code of Medical Ethics of the American Medical Association, so there is no specific prohibition against a dentist treating family members. The American Student Dental Association Ethics Code, Section III, Nonmaleficence and Beneficence, Part E, states, “Students should exercise discretion in treating family members due to problems associated with medical history disclosure, confidentiality, objectivity, and professionalism.”3 Even without a specific prohibition, there are several provisions within the ADA Code that should be taken into consideration in determining whether it is appropriate to provide care to family members. Section 1, Patient Autonomy (“selfgovernance”), states, “The dentist has a duty to respect the patient’s right to self-determination and confidentiality.”2 In the case of children, and especially minor children approaching the age at which they are involved in decision making about their own care, it may be difficult for the dentist to take the patient’s best interests into account if the dentist feels his or her professional judgment is more important than the child’s or relative’s desires. At the same time, a patientrelative may not feel able to refuse a recommendation for treatment for fear of offending his or her dentist-
September 2016
relative. Patient-relatives have the same rights as nonrelative patients, including informed consent and the need to hear all the risks, benefits, side effects, and alternatives to the proposed treatment and to participate in the decision-making process. In caring for a relative, the informed consent dialogue may be minimal or even nonexistent. Consideration of Section 2, Nonmaleficence (“do no harm”), is also critical: “This principle expresses the concept that professionals have a duty to protect the patient from harm.”2 Protection from harm includes knowing our skills and limitations and understanding when to refer a patient to a specialist. With a family member, a dentist may be tempted to provide care beyond his or her expertise or outside his or her training in an effort to make care more convenient or perhaps less costly for the relative. The risk in providing treatment that is below the standard of care is a concern as is the risk of causing actual harm to the patient-relative. Another concern may arise when taking a medical history of a close relative. There may be significant sensitive areas that the patient-relative may not wish to disclose to the dentist-relative or about which the dentist-relative might feel uncomfortable asking, which could result in an adverse outcome of the care being provided. Under Section 3, Beneficence (“do good”), the ADA Code states, “The dentist has a duty to promote the patient’s welfare.”2 It is entirely possible that a dentist’s relationship to the relative is such that the
FEATURES
dentist’s professional judgment may be clouded. Many of us have been encouraged in dental school always to treat our patients like they are family under the assumption that we would want only the best care for our own family members. In reality, we are parents, spouses, brothers, sisters, or in other ways related to our family just like everyone else, and we worry about the effect an experience may have on a relative, not wanting to cause the person pain or disappointment with unsuccessful care or other emotion-based concerns, which may make us less objective about what may be the best for our patientrelative. However, in emergency situations, or in the event no other provider is available, there should be no hesitation in providing whatever appropriate care we can to our family in the interest of their well-being. Researchers have developed a series of questions to ask to aid physicians in determining whether providing nonemergent care to family members is appropriate.4 These questions are adapted easily and appropriately for dental professionals: - Am I trained to address this dental need? - Am I too close to obtain intimate history and to cope with bearing bad news if need be?
Can I be objective enough not to overtreat, undertreat, or give inappropriate treatment? - Is my being dentally involved likely to cause or worsen family conflicts? - Is my relative more likely to comply with an unrelated dentist’s care plan? - Will I permit any dentist to whom I refer a relative to treat that relative? - Am I willing to be accountable to my peers and to the public for this care? If you can consider these questions objectively and answer them satisfactorily to determine that you are competent to provide care to your relative and have no conflict of interest, then from the standpoint of the ADA Code, you are free to provide dental care to your family members. n -
http://dx.doi.org/10.1016/j.adaj.2016.04.014 Copyright ª 2016 American Dental Association. All rights reserved.
Dr. Muller practices oral and maxillofacial surgery in Rapid City, SD, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Address correspondence to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, IL 60611.
Disclosure. Dr. Muller did not report any disclosures. Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, IL 60611, e-mail [email protected] or call the ethics hotline at 1-800-621-8099. The views expressed are those of the author and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA. 1. American Medical Association. Opinion 8.19—self-treatment or treatment of immediate family members. Available at: http://www.amaassn.org/ama/pub/physician-resources/medicalethics/code-medical-ethics/opinion819.page. Accessed January 27, 2016. 2. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. Available at: www.ada.org/sections/about/pdfs/ code_of_ethics_2012.pdf. Accessed January 27, 2016. 3. American Student Dental Association. ASDA ethics code. Available at: http://www. asdanet.org/codeofethics.aspx. Accessed January 27, 2016. 4. Douglas, S. Consider ethics, patient rights before treating your immediate family. American Medical News. April 13, 2009. Available at: http://www.amednews.com/article/20090413/ profession/304139977/5/. Accessed January 27, 2016.
JADA 147(9) http://jada.ada.org
September 2016 761