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Your mobile dental home
FEATURES
ETHICAL MOMENT
Your mobile dental home Douglas Auld, DDS
Q
I am a new dentist working for a company that operates a mobile dental van to perform examinations and obtain radiographs in community schools in a multistate area. They advertise that they are “your mobile dental home.” The company will only see Medicaid patients or children covered by insurance in which the complete fee is covered. They only perform examinations and obtain radiographs. I see patients, however, with active infections and other disease processes. My employer has instructed me that once the examination is completed, I am to provide a list of all dentists in the area and inform the patients (their parents) that treatment must be provided at some other facility. I have some ethical concerns about this and want to know what my options are.
A
Your situation raises several ethical issues. Some dentists do choose to limit their practice to diagnostic services, and the discussion that follows also applies to their efforts to practice in an ethical manner. First and foremost, you must remember to “have the benefit of the patient as [your] primary goal,” which is clearly stated in the preamble of the American Dental Association Principles of Ethics and Code of Professional Responsibility (ADA Code).1 With this as a foundation, let us explore some other areas of the ADA Code that are involved. Section 1 of the ADA Code addresses the principle of patient
280 JADA 146(4) http://jada.ada.org
autonomy. Section 1.A states that “The dentist should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.”1 In this case, however, the patient is a child and in a school setting and therefore cannot easily be involved in the decision-making process. Legally and ethically, the minor child cannot consent to treatment, but it is important to be sure that the parent is included in developing a course of treatment. Because parents may not be present at the time the patient is seen, having a method of informed consent that takes this into account is necessary. Another important question related to autonomy is ensuring that copies of the patient’s records are made available. Section 1.B of the ADA Code requires that dentists “maintain patient records in a manner consistent with the protection of the welfare of the patient.”1 In addition, if requested by the patient or another dentist, “dentists shall provide any information in accordance with applicable law that will be beneficial for the future treatment of the patient.”1 Even though the setting you describe is a mobile dental facility, the elements of patient autonomy cannot be compromised. Another section of the ADA Code that must be considered is Section 2, Nonmaleficence (“do no harm”). Under this section, “The dentist has a duty to refrain from harming the patient.”1 This obligation may require that the dentist consult with and refer patients to safeguard the welfare of the patient. Section 2.B imposes this obligation: “whenever
April 2015
the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience.”1 With the mobile dental office you describe, a system to ensure that the patients with active infection are properly cared for seems to be a necessity. In addition, if an issue occurs after the examination, identification of a true referral source for emergency or follow-up care is also necessary. Without adhering to these ethical obligations, questions about patient abandonment may arise. Section 2.F states, “. the dentist should not discontinue treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist. Care should be taken that the patient’s oral health is not jeopardized in the process.”1 This could be addressed by providing a list of other dentists to the patient, but a direct arrangement with those dentists for providing emergency care is necessary. In fact, Section 4.B of the ADA Code requires dentists “to make reasonable arrangements for the emergency care of their patients of record.”1 To ensure proper care, dentists practicing in the mobile unit must be willing and able to consult with other dentists to ensure proper care for the patient, including if an emergency arises. Another issue to be mindful of is how you are representing care to be certain that representations regarding care are not false. Section 5.F.2 presents an advisory opinion on examples of “False and Misleading.” The advisory opinion states, “Statements shall be avoided which would: a) contain a material misrepresentation of fact, b) omit a fact necessary
FEATURES
to make the statement considered as a whole not materially misleading, [or] c) be intended or be likely to create an unjustified expectation about results the dentist can achieve.”1 Advertising a mobile dental home without clarifying that the service provided is only diagnostic, with no expectation of treatment, could be somewhat misleading. After all, if only diagnostics and treatment planning are being performed, is this truly a “dental home,” as the name of the van indicates? You have a few options to ensure that you are practicing ethically. You must have systems in place for proper informed consent and parental or guardian involvement in treatment decisions. This must include an up-front discussion of the fact that only diagnosis and treatment planning are being offered, but
no treatment is being provided. This distinction should be very clear to the parent or guardian to truly respect his or her autonomy. A direct referral to a treating dentist of the parents’ choice and arrangements for emergency care should also be made. Finally, any advertisement should clearly describe the nature of the services being provided. If you feel that these issues cannot be resolved, then another practice setting may be more appropriate for you. n http://dx.doi.org/10.1016/j.adaj.2015.01.022 Copyright ª 2015 American Dental Association. All rights reserved.
Dr. Auld practices general dentistry in McAlester, OK, 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. Auld 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 Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. Available at: http://www.ada.org/w/media/ADA/About% 20the%20ADA/Files/code_of_ethics_2012.ashx. Accessed January 20, 2015.
JADA 146(4) http://jada.ada.org
April 2015 281
ETHICAL MOMENT
Your mobile dental home Douglas Auld, DDS
Q
I am a new dentist working for a company that operates a mobile dental van to perform examinations and obtain radiographs in community schools in a multistate area. They advertise that they are “your mobile dental home.” The company will only see Medicaid patients or children covered by insurance in which the complete fee is covered. They only perform examinations and obtain radiographs. I see patients, however, with active infections and other disease processes. My employer has instructed me that once the examination is completed, I am to provide a list of all dentists in the area and inform the patients (their parents) that treatment must be provided at some other facility. I have some ethical concerns about this and want to know what my options are.
A
Your situation raises several ethical issues. Some dentists do choose to limit their practice to diagnostic services, and the discussion that follows also applies to their efforts to practice in an ethical manner. First and foremost, you must remember to “have the benefit of the patient as [your] primary goal,” which is clearly stated in the preamble of the American Dental Association Principles of Ethics and Code of Professional Responsibility (ADA Code).1 With this as a foundation, let us explore some other areas of the ADA Code that are involved. Section 1 of the ADA Code addresses the principle of patient
280 JADA 146(4) http://jada.ada.org
autonomy. Section 1.A states that “The dentist should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.”1 In this case, however, the patient is a child and in a school setting and therefore cannot easily be involved in the decision-making process. Legally and ethically, the minor child cannot consent to treatment, but it is important to be sure that the parent is included in developing a course of treatment. Because parents may not be present at the time the patient is seen, having a method of informed consent that takes this into account is necessary. Another important question related to autonomy is ensuring that copies of the patient’s records are made available. Section 1.B of the ADA Code requires that dentists “maintain patient records in a manner consistent with the protection of the welfare of the patient.”1 In addition, if requested by the patient or another dentist, “dentists shall provide any information in accordance with applicable law that will be beneficial for the future treatment of the patient.”1 Even though the setting you describe is a mobile dental facility, the elements of patient autonomy cannot be compromised. Another section of the ADA Code that must be considered is Section 2, Nonmaleficence (“do no harm”). Under this section, “The dentist has a duty to refrain from harming the patient.”1 This obligation may require that the dentist consult with and refer patients to safeguard the welfare of the patient. Section 2.B imposes this obligation: “whenever
April 2015
the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience.”1 With the mobile dental office you describe, a system to ensure that the patients with active infection are properly cared for seems to be a necessity. In addition, if an issue occurs after the examination, identification of a true referral source for emergency or follow-up care is also necessary. Without adhering to these ethical obligations, questions about patient abandonment may arise. Section 2.F states, “. the dentist should not discontinue treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist. Care should be taken that the patient’s oral health is not jeopardized in the process.”1 This could be addressed by providing a list of other dentists to the patient, but a direct arrangement with those dentists for providing emergency care is necessary. In fact, Section 4.B of the ADA Code requires dentists “to make reasonable arrangements for the emergency care of their patients of record.”1 To ensure proper care, dentists practicing in the mobile unit must be willing and able to consult with other dentists to ensure proper care for the patient, including if an emergency arises. Another issue to be mindful of is how you are representing care to be certain that representations regarding care are not false. Section 5.F.2 presents an advisory opinion on examples of “False and Misleading.” The advisory opinion states, “Statements shall be avoided which would: a) contain a material misrepresentation of fact, b) omit a fact necessary
FEATURES
to make the statement considered as a whole not materially misleading, [or] c) be intended or be likely to create an unjustified expectation about results the dentist can achieve.”1 Advertising a mobile dental home without clarifying that the service provided is only diagnostic, with no expectation of treatment, could be somewhat misleading. After all, if only diagnostics and treatment planning are being performed, is this truly a “dental home,” as the name of the van indicates? You have a few options to ensure that you are practicing ethically. You must have systems in place for proper informed consent and parental or guardian involvement in treatment decisions. This must include an up-front discussion of the fact that only diagnosis and treatment planning are being offered, but
no treatment is being provided. This distinction should be very clear to the parent or guardian to truly respect his or her autonomy. A direct referral to a treating dentist of the parents’ choice and arrangements for emergency care should also be made. Finally, any advertisement should clearly describe the nature of the services being provided. If you feel that these issues cannot be resolved, then another practice setting may be more appropriate for you. n http://dx.doi.org/10.1016/j.adaj.2015.01.022 Copyright ª 2015 American Dental Association. All rights reserved.
Dr. Auld practices general dentistry in McAlester, OK, 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. Auld 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 Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. Available at: http://www.ada.org/w/media/ADA/About% 20the%20ADA/Files/code_of_ethics_2012.ashx. Accessed January 20, 2015.
JADA 146(4) http://jada.ada.org
April 2015 281