- Email: [email protected]
Respect for Patients' Autonomy
T R E N D S
B R I E F
R E P O R T
Respect for patients’ autonomy Kevin I. Reid, DMD, MS
onsider a situation in which a patient says to a dentist, “Somehow my dentist found out that I was coming to see you for a second opinion for my temporomandibular joint problem. He called me at work twice and then at home, where he finally caught me. I have no idea how he knew that I had an appointment with you—that really upset me. He told me that I should not keep my appointment with you because you only treat the symptoms, whereas he treats the cause. I felt like he was just after my money. I was so offended that he would do that. I will never go to him again and neither will anyone in my family.” The patient in this scenario also says she feels that her dentist was hounding her like a salesman who was fearful of losing a sale. Her perspective is that the professional boundary had been crossed in her relationship with the offending dentist. Patients do not expect that sort of behavior from a health care professional,1-3 but they do expect it in a competitive business environment.4
C
ABSTRACT Background. Respect for patients’ autonomy is an ethical principle in health care highlighted in the ADA Principles of Ethics and Code of Professional Conduct. The author presents a case example to illustrate its importance in dentistry. Methods. Using a clinical example of disrespect for patients’ autonomy, the author underscores the importance of incorporating normative ethical principles in patient-dentist relationships. Conclusions. Respect for patients’ autonomy sustains healthy boundaries between patients and the clinician. It underscores the importance of providing patient education and counsel without attempting to persuade or manipulate patients for dentists’ benefit. Practice Implications. Respect for patients’ autonomy is a fundamental principle of health care ethics that patients expect dentists to follow. The author encourages dentists to incorporate this principle into every patient encounter. Key Words. Dentists; ethics; informed consent; paternalism; personal autonomy; respect for patients’ autonomy. JADA 2009;140(4):470-474.
BUSINESS OR HEALTH CARE PROFESSION?
Is dentistry a business or a health care profession? Some people worry that 470
JADA, Vol. 140
http://jada.ada.org
Dr. Reid is an assistant professor, Department of Dental Specialties, Mayo Clinic, 200 First St. S.W., Rochester, Minn. 55905, e-mail “[email protected]”. Address reprint requests to Dr. Reid.
April 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
T R E N D S
dentistry has lost its way and has eschewed the virtues of professionalism, thereby changing from a health care profession to a for-profit enterprise1-3 and resulting in the sort of behavior about which the patient in the opening scenario complained. In fact, lay and professional publications have asked whether dentistry subscribes to the ethics of business or to the ethics of a profession.5,6 PATIENTS’ AUTONOMY
B R I E F
R E P O R T
are allowed to do so, “their maximal well-being will almost always be more efficiently produced . . . than if someone else chooses in their stead.”8 Furthermore, these authors underscored “a very special kind of satisfaction” from choosing one’s own actions and carrying them out within the context of one’s own “values, goals, principles, and ideals.”8 Thus, honoring and facilitating the autonomy of patients establishes a positive and supportive structure within which the therapeutic relationship may develop.
At the core of any clinical encounter in a health care setting is respect for patients’ autonomy, INFORMED CONSENT which, simply stated, is a principle that refers to the patient’s right to choose or decline a recThe dentist’s role in describing findings and recommendation without intimidation ommendations is part of the or pressure. Patients should be process of obtaining informed conThe dentist’s role able to make decisions for themsent, characterized by a discussion selves free from controlling interdesigned to foster understanding in describing ference and influences.7 This and not simply a disclosure of findings and means that a dental professional information. (Editor’s note: Denrecommendations is should approach a discussion tists should consult applicable part of the process of about a diagnosis by first edustate laws regarding informed conobtaining informed cating the patient about the sent.) The discussion about the consent. problem and articulating the recdiagnosis and treatment plan ommended treatment plan. Folshould include a dialogue about lowing the principle of respect for the rationale for and risks, benefits patients’ autonomy,7 he or she then should and goals of the suggested treatment, as well as encourage the patient to consider this informaany alternative treatments, all in the context of tion carefully and offer to answer questions, actively assisting the patient in making an with the ultimate goal of actively assisting the informed health care decision. patient in making an informed health care According to Beauchamp and Childress,7 the decision. fundamental criteria for informed consent It is important for the clinician to graciously include the following: accept the possibility that the decision may not dThe patient is competent to make independinclude acceptance of the proposed diagnosis or ent decisions. treatment. Any attempt to unduly influence a dThe patient’s decision is based on reasonable patient erodes the professional boundary and substantial disclosure by the dentist between dentists and patients. The dentist in regarding diagnosis and treatment the opening scenario assumed an “unwarranted recommendations. degree of authority over the patient,” potendThe patient has a reasonable degree of undertially compromising the patient’s autonomy,7 standing of the relevant issues (including alterand failed to demonstrate sensitivity regarding native choices). the considerable power differential between the dThe patient is acting voluntarily without dentist and the patient.6 undue influence. According to Ozar and Sokol,8 respecting dThe patient provides informed consent. patients’ autonomy “yields satisfaction for that The process of obtaining informed consent person [the patient] directly,” while interfering does not consist simply of a presentation of with an individual’s autonomy may be experiinformation. It should reflect the dentist’s effort enced as “a form of pain or suffering.” They to educate and discuss the findings with the highlighted the positive aspects of respecting patient and, out of respect for the patient’s patients’ autonomy by noting that when people autonomy, he or she then should encourage the who are capable of making autonomous choices patient to make oral health care decisions, JADA, Vol. 140
http://jada.ada.org
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
April 2009
471
T R E N D S
B R I E F
R E P O R T
without salesmanship, urging or persuasion by power differential to benefit themselves in any the dentist or dental staff members. As memway is a grievous violation of professional bers of a respected profession, dentists should standards11 and is inconsonant with common inform patients routinely about the range of morality and the fundamental moral precepts of treatments available in the dental community being a health care professional.10 (in this case, for temporomandibular disorders), Are there situations in which the dentist is acknowledging the various methods of diagnosis justified in discouraging a patient from seeking and treatment and underscoring their own protreatment from another dentist? Yes. If the denfessional approach without pejorative reference tist knows of another dentist’s intent to harm a to other people or treatment philosophies. patient in any way, the behavior described Anecdotally, in my experience, patients have above would be justified.8 Under circumstances responded to this approach with gratitude. such as those described in the opening scenario, Revealing options in this way conveys a sense of however, actively discouraging a patient from openness, confidence, respect for autonomy and seeking another opinion or being treated by professionalism. Among the benefits of engaging another dentist because of differences in treatpatients actively in an informed consent diament philosophy or the possible loss of income logue is the establishment of an not only violates the professional atmosphere of trust, thereby boundary between patient and Patients who have strengthening the dentist-patient dentist but reflects poorly on the the capacity to make dental profession in general. In relationship and reducing the likelihood of miscommunication and effect, it supports the emerging independent health litigation.9 However, as care decisions should view of dentistry as more of a Beauchamp and Childress7 pointed business in contrast with tradibe free to do so out, “from the moral viewpoint, tional concepts of dentistry as a without interference informed consent has less to do health care profession.2,8 from outside agents. with the liability of professionals How should one respond to the as agents of disclosure and more to situation in the opening scenario? do with the autonomous choices of The first concern should be what patients.” is best for the patient—not what may be best for Patients who have the capacity to make indethe dentist. Engaging a patient in an unflatpendent health care decisions should be free to tering conversation about another dentist or do so without interference from outside agents criticizing that dentist’s treatment approach is (including dentists) and should be afforded the not in the patient’s best interests and certainly respect they deserve to make choices regarding is not what a patient expects or needs in the their health care without gratuitous influence search for relief from a dental problem. Thus, by dentists or other health care practitioners the fundamentals of beneficence and professionwho want their business as clients or patients. alism suggest that the dentist respond by These basic concepts of respect for patients’ auassuring the patient that his or her only contonomy,7 along with the principles of beneficern is the patient’s welfare and by avoiding cence (doing good) and nonmaleficence (avoiding any disparaging remarks about the other denharm),10,11 undoubtedly have contributed to a tist or about comments that the other dentist high level of trust between patients and the may have made to the patient. dental profession.12 PATIENT-CENTERED COMMUNICATION Paternalism (that is, making decisions for patients without their informed input or As an example of a patient-centered and neutral insisting that they pursue care in only the way response, the dentist might say, “I can’t speak prescribed by the dentist) is an antiquated for what the other dentist told you, but I am manner of interacting with autonomous people eager to see how I may be able to help you, so and is inconsistent with the virtue of respect for let’s stay focused on that goal.” In the context of patients’ autonomy. It also reflects dentists’ informed consent, it is appropriate to acknowllack of respect for, or understanding of, the edge, without referring personally to a colpower differential between themselves and league, that treatment philosophies differ in the patients.6 For dentists to take advantage of this area of concern. For example, a dentist might 472
JADA, Vol. 140
http://jada.ada.org
April 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
T R E N D S
B R I E F
R E P O R T
say, “My approach to your situation is based on the other the greatest amount of what he or she my training and the literature, and it may be wants” and “the dentist is concerned about the different from approaches you’ve heard about patient’s well-being only as a means of before. Let’s talk about that, so you can make improving his or her own.”8 My assessment is an informed decision that’s best for you.” Alterthat dentistry as a profession is indeed comnatively, it may be prudent to say, “Although mitted to an ethic of health care that discourmy suggestions are different from the ones your ages a commercial or competitive business ethic. dentist has presented to you, I will do my best The dental profession will retain its honored to help you understand your diagnosis and my status as a health care profession as long as treatment suggestions and also answer any dentists are perceived as ethical, beneficent and questions about why I may not recommend trustworthy. Whether dentistry will retain that other types of treatments.” status if it comes to be perceived as a profitThe dentist could respond to the other dentist based industry rather than primarily as a with a collegial telephone conversation or perhealth care profession remains to be deterhaps a noninflammatory letter describing the mined. With each incident similar to that in the incident and making a request that the other opening scenario, the profession undergoes a dentist refrain from repeating this change, if not a reduction, in behavior for the good of patients stature that contributes to the perThe dental profession ception that instead of remaining and the profession. Continued incidents may warrant communiwill retain its honored professionals, dentists are cation with the appropriate status as a health care becoming purveyors in a wealthlicensing agency (for example, the enhancing for-profit enterprise. profession as long as state board of dentistry) or an dentists are perceived CONCLUSION attorney. as ethical, beneficent The collective professional PROFESSIONAL ETHICS and trustworthy. demeanor and behavior of dentists Does dentistry subscribe to an either will continue to reinforce ethic of business or to an ethic of a their historical role as profesprofession? Dentists fulfill the criteria of professionals committed to the compassionate and sionals in that they are specially trained and ethical provision of patient-centered oral health licensed, and they are committed to the provicare—or will insidiously transform the public’s sion of important health care services to their concept of dentistry to that of a for-profit compatients.7 In addition, dentistry as a profession mercial enterprise. If one assumes that this is self-regulating, and it controls who may or change is not favorable, and in light of the may not become a dentist through formal certiformal commitments by members of the fication processes.7 Furthermore, the formal American Dental Association to the principle of commitments made by members of the respect for patients’ autonomy,11 dentists should American Dental Association to the underlying embrace this principle with every patient and principles of conduct, as described in the ADA make every effort to avoid scenarios such as the Principles of Ethics and Code of Professional one presented at the outset. ■ Conduct,11 clearly establish the profession’s comDisclosure. Dr. Reid did not report any disclosures. mitment to the ethics of health care. These 1. Welie JV. Is dentistry a profession? Part 1. Professionalism ethics include the principles of respecting defined. J Can Dent Assoc 2004;70(8):529-532. patients’ autonomy, avoiding harm (nonmalefi2. Welie JV. Is dentistry a profession? Part 2. The hallmarks of cence) and doing good for others (beneficence). professionalism. J Can Dent Assoc 2004;70(9):599-602. 3. Welie JV. Is dentistry a profession? Part 3. Future challenges. J Collectively, these commitments implicitly Can Dent Assoc 2004;70(10):675-678. 8 reject what Ozar and Sokol have referred to as 4. Gini A. Moral leadership and business ethics. The James MacGregor Burns Academy of Leadership. “www.academy.umd.edu/ the “commercial model” of dentist-patient relaResources/publicationsindividual.asp?IDNumber=14”. Accessed Feb. tionships, in which “the only moral standards 15, 2009. 5. Berenson A. Boom times for dentists, but not for teeth. The New that apply to dentistry are those that apply to York Times. Oct. 11, 2007. “www.nytimes.com/2007/10/11/ every other bargainer in the marketplace.” business/11decay.html”. Accessed Feb. 15, 2009. 6. Reid KI, Mueller PS, Barnes SA. Attitudes of general dentists Within the commercial model, dentists and regarding the acceptance of gifts and unconventional payments from patients are competitors “trying to obtain from patients. JADA 2007;138(8):1127-1133. JADA, Vol. 140
http://jada.ada.org
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
April 2009
473
T R E N D S
B R I E F
R E P O R T
7. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York City: Oxford University Press; 2001:57-103. 8. Ozar DT, Sokol DJ. The relationship between patient and professional. In: Dental Ethics at Chairside: Professional Principles and Practical Applications. 2nd ed. Washington: Georgetown University Press; 2002:49, 53-54. 9. Graskemper JP. A new perspective on dental malpractice: practice enhancement through risk management. JADA 2002;133(6): 752-757.
474
JADA, Vol. 140
http://jada.ada.org
10. Pellegrino ED. Toward a virtue-based normative ethics for the health professions. Kennedy Inst Ethics J 1995;5(3):253-277. 11. ADA principles of ethics and code of professional conduct. Chicago: American Dental Association. “www.ada.org/prof/prac/ law/code/ada_code.pdf”. Accessed Feb. 15, 2009. 12. DiMatteo MR, McBride CA, Shugars DA, O’Neil EH. Public attitudes toward dentists: a U.S. household survey. JADA 1995;126(11):1563-1570.
April 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
B R I E F
R E P O R T
Respect for patients’ autonomy Kevin I. Reid, DMD, MS
onsider a situation in which a patient says to a dentist, “Somehow my dentist found out that I was coming to see you for a second opinion for my temporomandibular joint problem. He called me at work twice and then at home, where he finally caught me. I have no idea how he knew that I had an appointment with you—that really upset me. He told me that I should not keep my appointment with you because you only treat the symptoms, whereas he treats the cause. I felt like he was just after my money. I was so offended that he would do that. I will never go to him again and neither will anyone in my family.” The patient in this scenario also says she feels that her dentist was hounding her like a salesman who was fearful of losing a sale. Her perspective is that the professional boundary had been crossed in her relationship with the offending dentist. Patients do not expect that sort of behavior from a health care professional,1-3 but they do expect it in a competitive business environment.4
C
ABSTRACT Background. Respect for patients’ autonomy is an ethical principle in health care highlighted in the ADA Principles of Ethics and Code of Professional Conduct. The author presents a case example to illustrate its importance in dentistry. Methods. Using a clinical example of disrespect for patients’ autonomy, the author underscores the importance of incorporating normative ethical principles in patient-dentist relationships. Conclusions. Respect for patients’ autonomy sustains healthy boundaries between patients and the clinician. It underscores the importance of providing patient education and counsel without attempting to persuade or manipulate patients for dentists’ benefit. Practice Implications. Respect for patients’ autonomy is a fundamental principle of health care ethics that patients expect dentists to follow. The author encourages dentists to incorporate this principle into every patient encounter. Key Words. Dentists; ethics; informed consent; paternalism; personal autonomy; respect for patients’ autonomy. JADA 2009;140(4):470-474.
BUSINESS OR HEALTH CARE PROFESSION?
Is dentistry a business or a health care profession? Some people worry that 470
JADA, Vol. 140
http://jada.ada.org
Dr. Reid is an assistant professor, Department of Dental Specialties, Mayo Clinic, 200 First St. S.W., Rochester, Minn. 55905, e-mail “[email protected]”. Address reprint requests to Dr. Reid.
April 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
T R E N D S
dentistry has lost its way and has eschewed the virtues of professionalism, thereby changing from a health care profession to a for-profit enterprise1-3 and resulting in the sort of behavior about which the patient in the opening scenario complained. In fact, lay and professional publications have asked whether dentistry subscribes to the ethics of business or to the ethics of a profession.5,6 PATIENTS’ AUTONOMY
B R I E F
R E P O R T
are allowed to do so, “their maximal well-being will almost always be more efficiently produced . . . than if someone else chooses in their stead.”8 Furthermore, these authors underscored “a very special kind of satisfaction” from choosing one’s own actions and carrying them out within the context of one’s own “values, goals, principles, and ideals.”8 Thus, honoring and facilitating the autonomy of patients establishes a positive and supportive structure within which the therapeutic relationship may develop.
At the core of any clinical encounter in a health care setting is respect for patients’ autonomy, INFORMED CONSENT which, simply stated, is a principle that refers to the patient’s right to choose or decline a recThe dentist’s role in describing findings and recommendation without intimidation ommendations is part of the or pressure. Patients should be process of obtaining informed conThe dentist’s role able to make decisions for themsent, characterized by a discussion selves free from controlling interdesigned to foster understanding in describing ference and influences.7 This and not simply a disclosure of findings and means that a dental professional information. (Editor’s note: Denrecommendations is should approach a discussion tists should consult applicable part of the process of about a diagnosis by first edustate laws regarding informed conobtaining informed cating the patient about the sent.) The discussion about the consent. problem and articulating the recdiagnosis and treatment plan ommended treatment plan. Folshould include a dialogue about lowing the principle of respect for the rationale for and risks, benefits patients’ autonomy,7 he or she then should and goals of the suggested treatment, as well as encourage the patient to consider this informaany alternative treatments, all in the context of tion carefully and offer to answer questions, actively assisting the patient in making an with the ultimate goal of actively assisting the informed health care decision. patient in making an informed health care According to Beauchamp and Childress,7 the decision. fundamental criteria for informed consent It is important for the clinician to graciously include the following: accept the possibility that the decision may not dThe patient is competent to make independinclude acceptance of the proposed diagnosis or ent decisions. treatment. Any attempt to unduly influence a dThe patient’s decision is based on reasonable patient erodes the professional boundary and substantial disclosure by the dentist between dentists and patients. The dentist in regarding diagnosis and treatment the opening scenario assumed an “unwarranted recommendations. degree of authority over the patient,” potendThe patient has a reasonable degree of undertially compromising the patient’s autonomy,7 standing of the relevant issues (including alterand failed to demonstrate sensitivity regarding native choices). the considerable power differential between the dThe patient is acting voluntarily without dentist and the patient.6 undue influence. According to Ozar and Sokol,8 respecting dThe patient provides informed consent. patients’ autonomy “yields satisfaction for that The process of obtaining informed consent person [the patient] directly,” while interfering does not consist simply of a presentation of with an individual’s autonomy may be experiinformation. It should reflect the dentist’s effort enced as “a form of pain or suffering.” They to educate and discuss the findings with the highlighted the positive aspects of respecting patient and, out of respect for the patient’s patients’ autonomy by noting that when people autonomy, he or she then should encourage the who are capable of making autonomous choices patient to make oral health care decisions, JADA, Vol. 140
http://jada.ada.org
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
April 2009
471
T R E N D S
B R I E F
R E P O R T
without salesmanship, urging or persuasion by power differential to benefit themselves in any the dentist or dental staff members. As memway is a grievous violation of professional bers of a respected profession, dentists should standards11 and is inconsonant with common inform patients routinely about the range of morality and the fundamental moral precepts of treatments available in the dental community being a health care professional.10 (in this case, for temporomandibular disorders), Are there situations in which the dentist is acknowledging the various methods of diagnosis justified in discouraging a patient from seeking and treatment and underscoring their own protreatment from another dentist? Yes. If the denfessional approach without pejorative reference tist knows of another dentist’s intent to harm a to other people or treatment philosophies. patient in any way, the behavior described Anecdotally, in my experience, patients have above would be justified.8 Under circumstances responded to this approach with gratitude. such as those described in the opening scenario, Revealing options in this way conveys a sense of however, actively discouraging a patient from openness, confidence, respect for autonomy and seeking another opinion or being treated by professionalism. Among the benefits of engaging another dentist because of differences in treatpatients actively in an informed consent diament philosophy or the possible loss of income logue is the establishment of an not only violates the professional atmosphere of trust, thereby boundary between patient and Patients who have strengthening the dentist-patient dentist but reflects poorly on the the capacity to make dental profession in general. In relationship and reducing the likelihood of miscommunication and effect, it supports the emerging independent health litigation.9 However, as care decisions should view of dentistry as more of a Beauchamp and Childress7 pointed business in contrast with tradibe free to do so out, “from the moral viewpoint, tional concepts of dentistry as a without interference informed consent has less to do health care profession.2,8 from outside agents. with the liability of professionals How should one respond to the as agents of disclosure and more to situation in the opening scenario? do with the autonomous choices of The first concern should be what patients.” is best for the patient—not what may be best for Patients who have the capacity to make indethe dentist. Engaging a patient in an unflatpendent health care decisions should be free to tering conversation about another dentist or do so without interference from outside agents criticizing that dentist’s treatment approach is (including dentists) and should be afforded the not in the patient’s best interests and certainly respect they deserve to make choices regarding is not what a patient expects or needs in the their health care without gratuitous influence search for relief from a dental problem. Thus, by dentists or other health care practitioners the fundamentals of beneficence and professionwho want their business as clients or patients. alism suggest that the dentist respond by These basic concepts of respect for patients’ auassuring the patient that his or her only contonomy,7 along with the principles of beneficern is the patient’s welfare and by avoiding cence (doing good) and nonmaleficence (avoiding any disparaging remarks about the other denharm),10,11 undoubtedly have contributed to a tist or about comments that the other dentist high level of trust between patients and the may have made to the patient. dental profession.12 PATIENT-CENTERED COMMUNICATION Paternalism (that is, making decisions for patients without their informed input or As an example of a patient-centered and neutral insisting that they pursue care in only the way response, the dentist might say, “I can’t speak prescribed by the dentist) is an antiquated for what the other dentist told you, but I am manner of interacting with autonomous people eager to see how I may be able to help you, so and is inconsistent with the virtue of respect for let’s stay focused on that goal.” In the context of patients’ autonomy. It also reflects dentists’ informed consent, it is appropriate to acknowllack of respect for, or understanding of, the edge, without referring personally to a colpower differential between themselves and league, that treatment philosophies differ in the patients.6 For dentists to take advantage of this area of concern. For example, a dentist might 472
JADA, Vol. 140
http://jada.ada.org
April 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
T R E N D S
B R I E F
R E P O R T
say, “My approach to your situation is based on the other the greatest amount of what he or she my training and the literature, and it may be wants” and “the dentist is concerned about the different from approaches you’ve heard about patient’s well-being only as a means of before. Let’s talk about that, so you can make improving his or her own.”8 My assessment is an informed decision that’s best for you.” Alterthat dentistry as a profession is indeed comnatively, it may be prudent to say, “Although mitted to an ethic of health care that discourmy suggestions are different from the ones your ages a commercial or competitive business ethic. dentist has presented to you, I will do my best The dental profession will retain its honored to help you understand your diagnosis and my status as a health care profession as long as treatment suggestions and also answer any dentists are perceived as ethical, beneficent and questions about why I may not recommend trustworthy. Whether dentistry will retain that other types of treatments.” status if it comes to be perceived as a profitThe dentist could respond to the other dentist based industry rather than primarily as a with a collegial telephone conversation or perhealth care profession remains to be deterhaps a noninflammatory letter describing the mined. With each incident similar to that in the incident and making a request that the other opening scenario, the profession undergoes a dentist refrain from repeating this change, if not a reduction, in behavior for the good of patients stature that contributes to the perThe dental profession ception that instead of remaining and the profession. Continued incidents may warrant communiwill retain its honored professionals, dentists are cation with the appropriate status as a health care becoming purveyors in a wealthlicensing agency (for example, the enhancing for-profit enterprise. profession as long as state board of dentistry) or an dentists are perceived CONCLUSION attorney. as ethical, beneficent The collective professional PROFESSIONAL ETHICS and trustworthy. demeanor and behavior of dentists Does dentistry subscribe to an either will continue to reinforce ethic of business or to an ethic of a their historical role as profesprofession? Dentists fulfill the criteria of professionals committed to the compassionate and sionals in that they are specially trained and ethical provision of patient-centered oral health licensed, and they are committed to the provicare—or will insidiously transform the public’s sion of important health care services to their concept of dentistry to that of a for-profit compatients.7 In addition, dentistry as a profession mercial enterprise. If one assumes that this is self-regulating, and it controls who may or change is not favorable, and in light of the may not become a dentist through formal certiformal commitments by members of the fication processes.7 Furthermore, the formal American Dental Association to the principle of commitments made by members of the respect for patients’ autonomy,11 dentists should American Dental Association to the underlying embrace this principle with every patient and principles of conduct, as described in the ADA make every effort to avoid scenarios such as the Principles of Ethics and Code of Professional one presented at the outset. ■ Conduct,11 clearly establish the profession’s comDisclosure. Dr. Reid did not report any disclosures. mitment to the ethics of health care. These 1. Welie JV. Is dentistry a profession? Part 1. Professionalism ethics include the principles of respecting defined. J Can Dent Assoc 2004;70(8):529-532. patients’ autonomy, avoiding harm (nonmalefi2. Welie JV. Is dentistry a profession? Part 2. The hallmarks of cence) and doing good for others (beneficence). professionalism. J Can Dent Assoc 2004;70(9):599-602. 3. Welie JV. Is dentistry a profession? Part 3. Future challenges. J Collectively, these commitments implicitly Can Dent Assoc 2004;70(10):675-678. 8 reject what Ozar and Sokol have referred to as 4. Gini A. Moral leadership and business ethics. The James MacGregor Burns Academy of Leadership. “www.academy.umd.edu/ the “commercial model” of dentist-patient relaResources/publicationsindividual.asp?IDNumber=14”. Accessed Feb. tionships, in which “the only moral standards 15, 2009. 5. Berenson A. Boom times for dentists, but not for teeth. The New that apply to dentistry are those that apply to York Times. Oct. 11, 2007. “www.nytimes.com/2007/10/11/ every other bargainer in the marketplace.” business/11decay.html”. Accessed Feb. 15, 2009. 6. Reid KI, Mueller PS, Barnes SA. Attitudes of general dentists Within the commercial model, dentists and regarding the acceptance of gifts and unconventional payments from patients are competitors “trying to obtain from patients. JADA 2007;138(8):1127-1133. JADA, Vol. 140
http://jada.ada.org
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
April 2009
473
T R E N D S
B R I E F
R E P O R T
7. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York City: Oxford University Press; 2001:57-103. 8. Ozar DT, Sokol DJ. The relationship between patient and professional. In: Dental Ethics at Chairside: Professional Principles and Practical Applications. 2nd ed. Washington: Georgetown University Press; 2002:49, 53-54. 9. Graskemper JP. A new perspective on dental malpractice: practice enhancement through risk management. JADA 2002;133(6): 752-757.
474
JADA, Vol. 140
http://jada.ada.org
10. Pellegrino ED. Toward a virtue-based normative ethics for the health professions. Kennedy Inst Ethics J 1995;5(3):253-277. 11. ADA principles of ethics and code of professional conduct. Chicago: American Dental Association. “www.ada.org/prof/prac/ law/code/ada_code.pdf”. Accessed Feb. 15, 2009. 12. DiMatteo MR, McBride CA, Shugars DA, O’Neil EH. Public attitudes toward dentists: a U.S. household survey. JADA 1995;126(11):1563-1570.
April 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.