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Opinions of Dutch dentists on the introduction of new legislation in the field of Informed Consent. A pilot study
Patient Education and Counseling 28 (1996) 45-50
Opinions of Dutch dentists on the introduction of new legislation in the field of Informed Consent. A pilot study M.A.J. Eijkman*, The Department
of Social
Dentistry
H. Goedhart
and Dental Health Education, Academic Centre for Louwesweg 1, 1066 EA Amsterdam, The Netherlands
Dentistry
Amsterdam
(ACTA),
Received 22 April 1995; revised 6 October 1995; accepted 7 October 1995
Abstract This article describesthe resultsof four group discussionsheld with 34 Dutch dentiststo examine their opinion on the introduction of new legislationin the field of somepatient rights, particularly the duty to inform patients and the patient‘s authorization of a dental treatment procedure. From all the discussionsit appearsthat most are ignorant of the contents of the legislation. A number of important consequences for the practice are mentioned. Amongst the negative consequenceswhich are often named are: loss of income, a greater time investment per patient, the selectionof patients, more insuranceclaimsand an increasein administrationand keeping dossiers.The positive remarks that emergeare working with protocols, an increasein the quality of care and a better education of the patient. The discussiondrawsattention to the legal framework of the dentist-patient relationship, although it is not yet clear how certain aspectswill take shapein the daily dental practice. Keywords:
Informed Consent;Legislation; Social dentistry
1. Introduction ‘The enjoyment of the highest attainable standard of health is one of the most fundamental rights of every human being.......’ [l]. This principle, taken from the preamble of the charter of
the World
Health
Organization
(WHO),
ac-
cepted in 1946, is seen as the fundament of
international developments
patient legislation. Partly due to in health care, particularly in the
* Corresponding author. Tel.: 31 0 20 5188246, Fax: 31 0 20 5188233. 0738-3991/96/$15.00 PlI
0738-3991(96)00868-3
industrialized Western world, an internationally growing interest in patient rights is apparent. In Europe for example, the European parliament passed a motion on a European charter for patient rights in January 1984. Furthermore, many publications and articles in this area have backappeared, mostly of Anglo-American ground. In the Netherlands the debate on patient rights has been going on for more than 25 years. However, the law ‘Agreement on Medical Treatment’, passed by the Dutch government in 1994, seems to have ended the discussion for the
@ 19% Elsevier Science Ireland Ltd. All rights reserved
46
M.A.J.
Eijkman,
H. Goedhart
I Patient
Education
and Counseling
28 (1996)
45-50
moment. This law establishes the mutual rights and duties of patient and medical profession, resulting from the agreement on medical or dental treatment. The Dutch legislator has particularly helped to strengthen the patient‘s position in health care. Central to this regulation is the medical profession‘s duty to inform, a topic which gave rise to increasing debate amongst Dutch doctors, lawyers and ethicists in the past. Another important principle is the patient‘s authorization of a medical or dental treatment procedure. The medical or dental practitioner needs the patient‘s consent for every treatment. Without this consent the medical profession except in case of emergency - cannot start or continue any treatment. Furthermore, the law arranges a number of other patient rights, such as the right of access to one‘s medical file. Both key elements, the duty to inform and the authorization requirement, are closely linked. Only a well-informed patient can give sound permission for research or treatment. AngloAmerican literature speaks of ‘Informed Consent’ which, to the patient, means the equivalent of the two concepts combined; being informed about and giving one‘s consent to a particular treatment. Although in the past Dutch dental journals paid attention to the issue of ‘Informed Consent’ the Dutch Dental Association, the professional organization for Dutch dentists (NMT), saw the necessity to survey opinion on the introduction of the existing bill and the possible changes that might occur in professional practice. It was decided, at the end of 1993, to begin a study which formulates the following key questions. 1. In which situations do practising dentists consider the bill practicable? 2. Can one discern special conditions under which dentists consider the regulation practicable? 3. What are the consequences and implications for the dentist‘s daily work?
The results of the group discussions are integrated in the following. The dentist‘s points-ofview are summarized for each question. Due to the character of the study as a survey and the small size of the groups, no distinction has been made between the different districts.
2. Materials
3.1. Situations in which practising consider the bill practicable
and methods
Group discussion has been chosen as the research method. This qualitative method has the
advantage that a number of, as yet unanswered, questions can be put to a panel by means of a semi-structured interview. Whilst allowing little generalization, this method provides an opening to search for opinions. Dentists from four districts in different parts of the Netherlands were approached to collaborate. These districts were situated around the cities of Zwolle, Utrecht, the Hague and Eindhoven and have been chosen to achieve a wide spread of participants. Thirty general practitioners were selected from each district, based on a random sampling carried out by the NMT. They first received an invitation and a reminder 3 weeks later. Forty-one of the dentists approached (N = 120) promised to participate. The eventual number of participants was 34, of which 26 were male and 8 were female. The average time between graduation and participation in this research was 13.5 years, S.D. = 7.9 years. The oldest dentist had been in practice for 39 years, the youngest for 2 years. The group discussions took place using a number of questions that were mostly drawn from American literature. Besides, these questionnaires were supplemented by data from an interview held with a jurist and specialist in the field of public health legislation. The scheme of questions comprised the three aforementioned main questions, followed by 1.5 questions that were closely connected. The duration of the discussions was - 2 h and the answers were recorded on tape. This article will only deal with the three main questions.
3. Results
Initially, many dentists think regulations were impracticable.
dentists that the former What can be
M.A.J.
Eijkman,
H. Goedhart
I Patient
done depends on a number of circumstances, such as: - the kind of treatment, - the scope of treatment; routine versus a more complicated treatment, - the legal climate (society‘s legislation), - the communication between dentist and patient, - the patient‘s intellectual grasp and level of education, - the patient‘s wish that the dentist make the decision, - adequate financial reward, - problems with work load. Participants in the discussions appear to interpret the regulation in two ways: on the one hand, to be flexible (‘actually we already do that’) and on the other, to be strict and formal and stress signing consent forms. A number of dentists worry about the possible extra workload, whereas others say that they have already integrated the necessary information in the treatment. However, for the majority of dentists in this group, ‘Informed Consent’ as presented, seems to form a threat to the profession. Furthermore, one gets the impression that there is a widespread unfamiliarity with the content and the background of the bill. Without exception all participants felt that even in the case of routine treatment, such as a simple filling, consent should have to be asked. 3.2. Conditions under which dentists consider the regulation practicable
Many dentists find the question ‘Can one discern special conditions under which dentists consider the regulation practicable?’ difficult to answer. In most cases there is a strong belief that dentists have received too limited an education, as far as reviewing the many medical consequences of certain treatments is concerned. A further opinion is that one needs extensive data for each patient e.g. periodontics or X-ray status, in order to comply with the law‘s point of departure. It is also thought that the patientdentist relationship, which is based on trust, may suffer. Some dentists note that patients find it hard to decide themselves, since they continually
Education
and Counseling
28 (19%)
4.5-50
47
have to rely on their dentist‘s know-how. A burning question for a number of participants is whether special arrangements can be made for the treatment of children and specific groups, such as geriatric patients or immigrants from for instance Morocco and Turkey. In conclusion, participants think that they should first know everything about the patient before they can adequately inform him or her and ask consent. A better case-history and registration of the patient‘s treatment may perhaps lead to a situation in which ‘Informed Consent’ can be put into practice.
3.3. The consequences dentist‘s daily work
and implications
for the
In answering the question ‘What are the consequences and implications for the dentist‘s daily work?’ a wide range of possible consequences emerge. Besides some relativizing remarks such as, ‘it will turn out to be better than anticipated’, one finds the following pattern of answers. Aspects which can better be classified under personal circumstances. The professional aspects mentioned are: - more computer work in connection with drawing up more estimates etc., - a shift towards more paperwork; recording agreements more often, - working with more standardized protocols, - better information for the patient, - fear of American situations, i.e. more insurance claims, - the relation between administration and actual treatment will become even more distorted than it is now, - the discrepancy between administration and prices will increase, - the number of non-declarable hours, e.g. evening work, will increase, - observed overtreatment, - selection of patients, e.g. patients that are seen as difficult are less likely to be selected for treatment. Aspects mentioned in the private sphere include: - the role of the treating dentist becomes clearer
48
M.A.J.
Eijkman.
H. Goedhart
I Patient
if things are recorded in writing, a good file is a help, - the free trade will be affected, - implementing the law will increase stress, - post-graduate courses in the field of conducting conversations will appear necessary. It is striking that a great number of consequences and implications are mentioned. These can mainly be characterized as negative, e.g. implementing this law will cost more time per patient, will lead to more extensive administration, the practice will generate less income and, in financial terms, it is not practicable. However, quality stimulating effects are also recognized, such as achieving greater uniformity in dental care, better information for the patient and introducing records.
4. Discussion
By lawful establishment of the dentist-patient relationship, the right to obtain information and the obligatory consent, a relationship previously based on trust will also acquire a legal framework. Dutch jurists and lawyers expect that, as far as the medical and dental practice is concerned, little will change [2]. After all, the legislation can be seen as a codification of already existing written and unwritten laws. 4.1. Doubts There are doubts, even though the statutory regulation actually formulates general rules. The question posed from a legal point of view is how medical practitioners will handle the law in their daily work [3]. American literature also points out that the consequence of the ‘Informed Consent’ doctrine is not yet very clear [4]. Our research seems to confirm these doubts. On the one hand, it can be seen that a number of dentists in this group are already accustomed to informing the patient about the treatment. On the other hand, and on a much larger scale, there seems to be some reservation as to what the future with the obligatory ‘Informed Consent’ will look like.
Education
and Counseling
28 (1996)
45-50
The most important negative consequence pointed out by the participants concerns the financial sphere. In general one fears loss of income, since informing patients takes time which results in fewer treatments. One wonders whether, within existing or new Dutch dental remuneration and insurance regulations and policies, the time investment resulting from the obligation to provide information will be financially compensated. After all, when for the smallest treatment one has to provide information about the possible alternatives, about the possible negative consequences and the treatments that will be carried out, then this increased time investment seems a realistic view. However, when one takes a closer look at the negative consequences, one gets the impression that the participants are not well-informed about the basic assumptions of the bill in which the right to information is arranged. After all, it is not intended that the patient be elaborately informed on every small matter; sometimes the information may even be superfluous [3]. Routine treatments will take place as accustomed. If one observes the current rules of conduct and explains to the patient what to expect, e.g. the cost of treatment, outlines possible alternatives and answer the patient‘s questions, the dental practice will change little. The provision of thorough information applies chiefly to extensive treatments. A number of participants were already familiar with this procedure. Although dentists are unclear about the quantity of information needed, in general it can be stated that the information should be such that it enables the patient to make a balanced decision. Special risks and infrequent side effects can, as a rule, be left aside. Detailed instructions are pointless and cannot be given [5]. Furthermore participants expressed their fear for the increase of ‘American situations’ and an increase in the number of insurance claims within the field of dental care. In the Netherlands this fear seems to be exaggerated. There is no comparison between the situation in the United States and in the Netherlands as regards holding the medical profession liable. In the Netherlands the number of insurance claims is significantly
M.A.J.
Eijkman,
H. Goedhart
I Patient
lower than those in the United States. Amongst other things this may be due to the absence of social security regulations in the United States (so that the patient has to go to the medical profession to get compensation), the American legal system and the general climate as far as getting compensation is concerned. The literature indicates little support for the negative aspects which, according to the participants, are linked to ‘Informed Consent’, such as extra time investment. From several studies, though outside the field of dentistry, it appears that good advice will eventually result in saving time and an increase in loyalty to the therapist, especially when it concerns a drastic treatment [6-91. Doctors too used to mention the time argument but, according to the literature, they have reconsidered. The right amount of information given at the right moment has an educational effect. By a subsequent next treatment the patient will be better informed about its aim and purpose. For the time being these positive experiences are not yet known in the (Dutch) dental practice. Most research is originally American and mainly carried out in regular medical locations. The second argument, that ‘Informed Consent’ can have a preventative and time saving effect, emerges when one considers what can happen when information and consent have been omitted and the patient starts a procedure. Moreover, from the literature mentioned above, it appears that well-informed patients are less likely to initiate a lawsuit. Several of the legislation‘s quality promoting effects are recognized by the participants. The medical profession must work in a more systematic way by means of standardized protocols. More so than in the past, the choice of treatment need not only be made by the dentist but will ask a more active role of the patient. The ‘overtreatment’ predicted by many participants, mainly amounts to carrying out more diagnoses and fewer risky treatments. More diagnoses for instance means that all the patients records, such as extensive X-ray and other time consuming diagnostic procedures, must be avail-
Education
and Counseling
28 (19%)
45-50
49
able from the start, in order to be well-documented in case of a possible lawsuit. One covers oneself more quickly than was usual in the past. It is anticipated that where a treatment carries a clear element of risk, the dentist will be less inclined to make compromises easily. By carrying out more, and non-urgent treatments, aimed to protect himself, the dentist may believe himself to be safe. Yet the question is whether these arguments are true. After all, the extent of treatment is determined by professional attitudes and is independent of the information that has to be given and obtaining the patient‘s permission. On the other hand, the wish to use protocols might actually lead to more diagnoses and as such fit in with the wish to work more efficiently.
4.2. Consent
An important part of the bill deals with two different requirements: consent given at the start of a treatment and consent given to perform the treatment. The participants in this study do not see these two different consent requirements as separate entities. In most cases dentists take it for granted that, when a patient enters his practice, treatment can and may be begun: implied consent. From discussions at the group meetings it appears that most dentists do not connect ‘Informed Consent’ to private law arrangements, such as entering into an agreement, acting justly and fairly. However, these aspects are inextricably bound up with the daily dental practice in which entering into ‘contracts’ and making agreements is a recurring phenomenon. Obtaining the patient’s consent need not be expressed in writing or by spoken word, but it can also appear from behaviour. An article [lo] quotes an example where, after the dentist has informed a patient about the extraction of a molar, this patient agrees to the proposed treatment by making an appointment and showing up at the agreed time. As a general guideline one should observe: the more extensive the treatment, the more information should be given to the patient to enable him to come to a balanced conclusion.
50
M.A.J.
Eijkman.
H. Goedhart
I Patient
5. Conclusions
This article illustrates the issue of ‘Informed Consent’, experienced by a group of general dentists, as extremely complicated. The number of respondents was disappointing; 34 out of the 120 dentists approached. Nevertheless, taking into consideration the qualitative character of the study, the results provide a clear picture of the various opinions of dentists regarding the issue of ‘Informed Consent’. During each group discussion one could sense a general tendency towards a defensive attitude concerning the patient‘s right to information and informed consent. On the other hand, several participants do not close their eyes to the positive results of introducing the bill. It is difficult to anticipate how this new legislation will work out for the Dutch dental practice. Possibly jurist and lawyers take an easier view than dentists in this matter. However, it is clear that, in the case of these dental professionals, some resistance will have to be overcome. An aspect which also appears in other medical fields, such as the treatment of breast cancer patients by oncologists [ll], or where doctor‘s anticipate negative consequences from informing a patient [12]. When the bill was debated by the Dutch parliament, it was nevertheless decided that, 5 years after the date of commencement, the legislation will be evaluated. Therefore, it seems wise to regularly research the consequences of the new law as regards the relationship between (dental) health workers and patients.
Education
and Counseling
28 (1996)
45-50
References
111World
Health Organisation. Basic Documents. Geneva, 1973. PI Van der Horst JA. Wet Geneeskundige Behandelingsovereenkomst geen omwenteling in de gezondheidszorg. Ned Tandartsenblad 1995; 50: 22-23. 131 Roscam Abbing HDC. Het Recht op Informatie in de Medische Praktijk. Ned Tijdschr Geneeskd 1993; 137: 1861-1863. [41 Bailey BL. Informed Consent in Dentistry. JAM Dent Assoc 1985; 110: 709-714. PI Roscam Abbing HDC. Rechten van patienten: individuele en sociale grondrechten in de gezondheidszorg. In: de Beaufort, ID and Dupuis, HM, editors. Handboek Gezondheidsethiek Asset-i/Maastricht: Van Gorcum, 1988. 161Selbst AG. Understanding informed consent and its relationship to the incidence of adverse treatment events in conventional endodontic therapy. J End 1990; 16: 387-390. [71 Strull WM, Lo B, Charles G. Do patients want to participate in medical decision-making? J Am Med Assoc 1984; 252: 2990-2994. PI O‘Connor RJ. Informed Consent: legal behavioral and educational issues. Patient Couns Health Educ 1981; 3: 49-56. [91 Van Zuuren F, De Boer J. Het recht op informatie: empirische aantekeningen bij een wetsvoorstel. De Psycholoog 1988; 23: 623-628. WI Myers WR. Informed Consent. Oral and maxillofacial surgery. Clin North Am 1993; 5(l): 179-184. WI Taylor KM, Kelner M. Informed Consent: the physicians‘ perspective. Sot Sci Med 1987; 24: 135-143. WI Faden RR, Becker C, Lewis C, Freeman J, Faden AI. Disclosure of information to patients in medical care. Med Care 1981; 19: 718-733.
Opinions of Dutch dentists on the introduction of new legislation in the field of Informed Consent. A pilot study M.A.J. Eijkman*, The Department
of Social
Dentistry
H. Goedhart
and Dental Health Education, Academic Centre for Louwesweg 1, 1066 EA Amsterdam, The Netherlands
Dentistry
Amsterdam
(ACTA),
Received 22 April 1995; revised 6 October 1995; accepted 7 October 1995
Abstract This article describesthe resultsof four group discussionsheld with 34 Dutch dentiststo examine their opinion on the introduction of new legislationin the field of somepatient rights, particularly the duty to inform patients and the patient‘s authorization of a dental treatment procedure. From all the discussionsit appearsthat most are ignorant of the contents of the legislation. A number of important consequences for the practice are mentioned. Amongst the negative consequenceswhich are often named are: loss of income, a greater time investment per patient, the selectionof patients, more insuranceclaimsand an increasein administrationand keeping dossiers.The positive remarks that emergeare working with protocols, an increasein the quality of care and a better education of the patient. The discussiondrawsattention to the legal framework of the dentist-patient relationship, although it is not yet clear how certain aspectswill take shapein the daily dental practice. Keywords:
Informed Consent;Legislation; Social dentistry
1. Introduction ‘The enjoyment of the highest attainable standard of health is one of the most fundamental rights of every human being.......’ [l]. This principle, taken from the preamble of the charter of
the World
Health
Organization
(WHO),
ac-
cepted in 1946, is seen as the fundament of
international developments
patient legislation. Partly due to in health care, particularly in the
* Corresponding author. Tel.: 31 0 20 5188246, Fax: 31 0 20 5188233. 0738-3991/96/$15.00 PlI
0738-3991(96)00868-3
industrialized Western world, an internationally growing interest in patient rights is apparent. In Europe for example, the European parliament passed a motion on a European charter for patient rights in January 1984. Furthermore, many publications and articles in this area have backappeared, mostly of Anglo-American ground. In the Netherlands the debate on patient rights has been going on for more than 25 years. However, the law ‘Agreement on Medical Treatment’, passed by the Dutch government in 1994, seems to have ended the discussion for the
@ 19% Elsevier Science Ireland Ltd. All rights reserved
46
M.A.J.
Eijkman,
H. Goedhart
I Patient
Education
and Counseling
28 (1996)
45-50
moment. This law establishes the mutual rights and duties of patient and medical profession, resulting from the agreement on medical or dental treatment. The Dutch legislator has particularly helped to strengthen the patient‘s position in health care. Central to this regulation is the medical profession‘s duty to inform, a topic which gave rise to increasing debate amongst Dutch doctors, lawyers and ethicists in the past. Another important principle is the patient‘s authorization of a medical or dental treatment procedure. The medical or dental practitioner needs the patient‘s consent for every treatment. Without this consent the medical profession except in case of emergency - cannot start or continue any treatment. Furthermore, the law arranges a number of other patient rights, such as the right of access to one‘s medical file. Both key elements, the duty to inform and the authorization requirement, are closely linked. Only a well-informed patient can give sound permission for research or treatment. AngloAmerican literature speaks of ‘Informed Consent’ which, to the patient, means the equivalent of the two concepts combined; being informed about and giving one‘s consent to a particular treatment. Although in the past Dutch dental journals paid attention to the issue of ‘Informed Consent’ the Dutch Dental Association, the professional organization for Dutch dentists (NMT), saw the necessity to survey opinion on the introduction of the existing bill and the possible changes that might occur in professional practice. It was decided, at the end of 1993, to begin a study which formulates the following key questions. 1. In which situations do practising dentists consider the bill practicable? 2. Can one discern special conditions under which dentists consider the regulation practicable? 3. What are the consequences and implications for the dentist‘s daily work?
The results of the group discussions are integrated in the following. The dentist‘s points-ofview are summarized for each question. Due to the character of the study as a survey and the small size of the groups, no distinction has been made between the different districts.
2. Materials
3.1. Situations in which practising consider the bill practicable
and methods
Group discussion has been chosen as the research method. This qualitative method has the
advantage that a number of, as yet unanswered, questions can be put to a panel by means of a semi-structured interview. Whilst allowing little generalization, this method provides an opening to search for opinions. Dentists from four districts in different parts of the Netherlands were approached to collaborate. These districts were situated around the cities of Zwolle, Utrecht, the Hague and Eindhoven and have been chosen to achieve a wide spread of participants. Thirty general practitioners were selected from each district, based on a random sampling carried out by the NMT. They first received an invitation and a reminder 3 weeks later. Forty-one of the dentists approached (N = 120) promised to participate. The eventual number of participants was 34, of which 26 were male and 8 were female. The average time between graduation and participation in this research was 13.5 years, S.D. = 7.9 years. The oldest dentist had been in practice for 39 years, the youngest for 2 years. The group discussions took place using a number of questions that were mostly drawn from American literature. Besides, these questionnaires were supplemented by data from an interview held with a jurist and specialist in the field of public health legislation. The scheme of questions comprised the three aforementioned main questions, followed by 1.5 questions that were closely connected. The duration of the discussions was - 2 h and the answers were recorded on tape. This article will only deal with the three main questions.
3. Results
Initially, many dentists think regulations were impracticable.
dentists that the former What can be
M.A.J.
Eijkman,
H. Goedhart
I Patient
done depends on a number of circumstances, such as: - the kind of treatment, - the scope of treatment; routine versus a more complicated treatment, - the legal climate (society‘s legislation), - the communication between dentist and patient, - the patient‘s intellectual grasp and level of education, - the patient‘s wish that the dentist make the decision, - adequate financial reward, - problems with work load. Participants in the discussions appear to interpret the regulation in two ways: on the one hand, to be flexible (‘actually we already do that’) and on the other, to be strict and formal and stress signing consent forms. A number of dentists worry about the possible extra workload, whereas others say that they have already integrated the necessary information in the treatment. However, for the majority of dentists in this group, ‘Informed Consent’ as presented, seems to form a threat to the profession. Furthermore, one gets the impression that there is a widespread unfamiliarity with the content and the background of the bill. Without exception all participants felt that even in the case of routine treatment, such as a simple filling, consent should have to be asked. 3.2. Conditions under which dentists consider the regulation practicable
Many dentists find the question ‘Can one discern special conditions under which dentists consider the regulation practicable?’ difficult to answer. In most cases there is a strong belief that dentists have received too limited an education, as far as reviewing the many medical consequences of certain treatments is concerned. A further opinion is that one needs extensive data for each patient e.g. periodontics or X-ray status, in order to comply with the law‘s point of departure. It is also thought that the patientdentist relationship, which is based on trust, may suffer. Some dentists note that patients find it hard to decide themselves, since they continually
Education
and Counseling
28 (19%)
4.5-50
47
have to rely on their dentist‘s know-how. A burning question for a number of participants is whether special arrangements can be made for the treatment of children and specific groups, such as geriatric patients or immigrants from for instance Morocco and Turkey. In conclusion, participants think that they should first know everything about the patient before they can adequately inform him or her and ask consent. A better case-history and registration of the patient‘s treatment may perhaps lead to a situation in which ‘Informed Consent’ can be put into practice.
3.3. The consequences dentist‘s daily work
and implications
for the
In answering the question ‘What are the consequences and implications for the dentist‘s daily work?’ a wide range of possible consequences emerge. Besides some relativizing remarks such as, ‘it will turn out to be better than anticipated’, one finds the following pattern of answers. Aspects which can better be classified under personal circumstances. The professional aspects mentioned are: - more computer work in connection with drawing up more estimates etc., - a shift towards more paperwork; recording agreements more often, - working with more standardized protocols, - better information for the patient, - fear of American situations, i.e. more insurance claims, - the relation between administration and actual treatment will become even more distorted than it is now, - the discrepancy between administration and prices will increase, - the number of non-declarable hours, e.g. evening work, will increase, - observed overtreatment, - selection of patients, e.g. patients that are seen as difficult are less likely to be selected for treatment. Aspects mentioned in the private sphere include: - the role of the treating dentist becomes clearer
48
M.A.J.
Eijkman.
H. Goedhart
I Patient
if things are recorded in writing, a good file is a help, - the free trade will be affected, - implementing the law will increase stress, - post-graduate courses in the field of conducting conversations will appear necessary. It is striking that a great number of consequences and implications are mentioned. These can mainly be characterized as negative, e.g. implementing this law will cost more time per patient, will lead to more extensive administration, the practice will generate less income and, in financial terms, it is not practicable. However, quality stimulating effects are also recognized, such as achieving greater uniformity in dental care, better information for the patient and introducing records.
4. Discussion
By lawful establishment of the dentist-patient relationship, the right to obtain information and the obligatory consent, a relationship previously based on trust will also acquire a legal framework. Dutch jurists and lawyers expect that, as far as the medical and dental practice is concerned, little will change [2]. After all, the legislation can be seen as a codification of already existing written and unwritten laws. 4.1. Doubts There are doubts, even though the statutory regulation actually formulates general rules. The question posed from a legal point of view is how medical practitioners will handle the law in their daily work [3]. American literature also points out that the consequence of the ‘Informed Consent’ doctrine is not yet very clear [4]. Our research seems to confirm these doubts. On the one hand, it can be seen that a number of dentists in this group are already accustomed to informing the patient about the treatment. On the other hand, and on a much larger scale, there seems to be some reservation as to what the future with the obligatory ‘Informed Consent’ will look like.
Education
and Counseling
28 (1996)
45-50
The most important negative consequence pointed out by the participants concerns the financial sphere. In general one fears loss of income, since informing patients takes time which results in fewer treatments. One wonders whether, within existing or new Dutch dental remuneration and insurance regulations and policies, the time investment resulting from the obligation to provide information will be financially compensated. After all, when for the smallest treatment one has to provide information about the possible alternatives, about the possible negative consequences and the treatments that will be carried out, then this increased time investment seems a realistic view. However, when one takes a closer look at the negative consequences, one gets the impression that the participants are not well-informed about the basic assumptions of the bill in which the right to information is arranged. After all, it is not intended that the patient be elaborately informed on every small matter; sometimes the information may even be superfluous [3]. Routine treatments will take place as accustomed. If one observes the current rules of conduct and explains to the patient what to expect, e.g. the cost of treatment, outlines possible alternatives and answer the patient‘s questions, the dental practice will change little. The provision of thorough information applies chiefly to extensive treatments. A number of participants were already familiar with this procedure. Although dentists are unclear about the quantity of information needed, in general it can be stated that the information should be such that it enables the patient to make a balanced decision. Special risks and infrequent side effects can, as a rule, be left aside. Detailed instructions are pointless and cannot be given [5]. Furthermore participants expressed their fear for the increase of ‘American situations’ and an increase in the number of insurance claims within the field of dental care. In the Netherlands this fear seems to be exaggerated. There is no comparison between the situation in the United States and in the Netherlands as regards holding the medical profession liable. In the Netherlands the number of insurance claims is significantly
M.A.J.
Eijkman,
H. Goedhart
I Patient
lower than those in the United States. Amongst other things this may be due to the absence of social security regulations in the United States (so that the patient has to go to the medical profession to get compensation), the American legal system and the general climate as far as getting compensation is concerned. The literature indicates little support for the negative aspects which, according to the participants, are linked to ‘Informed Consent’, such as extra time investment. From several studies, though outside the field of dentistry, it appears that good advice will eventually result in saving time and an increase in loyalty to the therapist, especially when it concerns a drastic treatment [6-91. Doctors too used to mention the time argument but, according to the literature, they have reconsidered. The right amount of information given at the right moment has an educational effect. By a subsequent next treatment the patient will be better informed about its aim and purpose. For the time being these positive experiences are not yet known in the (Dutch) dental practice. Most research is originally American and mainly carried out in regular medical locations. The second argument, that ‘Informed Consent’ can have a preventative and time saving effect, emerges when one considers what can happen when information and consent have been omitted and the patient starts a procedure. Moreover, from the literature mentioned above, it appears that well-informed patients are less likely to initiate a lawsuit. Several of the legislation‘s quality promoting effects are recognized by the participants. The medical profession must work in a more systematic way by means of standardized protocols. More so than in the past, the choice of treatment need not only be made by the dentist but will ask a more active role of the patient. The ‘overtreatment’ predicted by many participants, mainly amounts to carrying out more diagnoses and fewer risky treatments. More diagnoses for instance means that all the patients records, such as extensive X-ray and other time consuming diagnostic procedures, must be avail-
Education
and Counseling
28 (19%)
45-50
49
able from the start, in order to be well-documented in case of a possible lawsuit. One covers oneself more quickly than was usual in the past. It is anticipated that where a treatment carries a clear element of risk, the dentist will be less inclined to make compromises easily. By carrying out more, and non-urgent treatments, aimed to protect himself, the dentist may believe himself to be safe. Yet the question is whether these arguments are true. After all, the extent of treatment is determined by professional attitudes and is independent of the information that has to be given and obtaining the patient‘s permission. On the other hand, the wish to use protocols might actually lead to more diagnoses and as such fit in with the wish to work more efficiently.
4.2. Consent
An important part of the bill deals with two different requirements: consent given at the start of a treatment and consent given to perform the treatment. The participants in this study do not see these two different consent requirements as separate entities. In most cases dentists take it for granted that, when a patient enters his practice, treatment can and may be begun: implied consent. From discussions at the group meetings it appears that most dentists do not connect ‘Informed Consent’ to private law arrangements, such as entering into an agreement, acting justly and fairly. However, these aspects are inextricably bound up with the daily dental practice in which entering into ‘contracts’ and making agreements is a recurring phenomenon. Obtaining the patient’s consent need not be expressed in writing or by spoken word, but it can also appear from behaviour. An article [lo] quotes an example where, after the dentist has informed a patient about the extraction of a molar, this patient agrees to the proposed treatment by making an appointment and showing up at the agreed time. As a general guideline one should observe: the more extensive the treatment, the more information should be given to the patient to enable him to come to a balanced conclusion.
50
M.A.J.
Eijkman.
H. Goedhart
I Patient
5. Conclusions
This article illustrates the issue of ‘Informed Consent’, experienced by a group of general dentists, as extremely complicated. The number of respondents was disappointing; 34 out of the 120 dentists approached. Nevertheless, taking into consideration the qualitative character of the study, the results provide a clear picture of the various opinions of dentists regarding the issue of ‘Informed Consent’. During each group discussion one could sense a general tendency towards a defensive attitude concerning the patient‘s right to information and informed consent. On the other hand, several participants do not close their eyes to the positive results of introducing the bill. It is difficult to anticipate how this new legislation will work out for the Dutch dental practice. Possibly jurist and lawyers take an easier view than dentists in this matter. However, it is clear that, in the case of these dental professionals, some resistance will have to be overcome. An aspect which also appears in other medical fields, such as the treatment of breast cancer patients by oncologists [ll], or where doctor‘s anticipate negative consequences from informing a patient [12]. When the bill was debated by the Dutch parliament, it was nevertheless decided that, 5 years after the date of commencement, the legislation will be evaluated. Therefore, it seems wise to regularly research the consequences of the new law as regards the relationship between (dental) health workers and patients.
Education
and Counseling
28 (1996)
45-50
References
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