Solving ethical dilemmas in dental hygiene practice

www.rdhmag.comDecember 04, 2020

By Marcy Ortiz, RDH, BA

Ethics is a difficult concept to define because it is viewed very differently

depending on the particular dilemma. Doing the right thing when confronted with a
difficult circumstance is one way to define ethical behavior. Ethical is also
defined as “maximizing the good while minimizing the bad,”1 or according to Merriam
Webster, ethics is “the discipline dealing with what is good and bad and with moral
duty and obligation.”2 Another definition is being professional and being able to
deal with morally perplexing situations.3 Regardless of the definition, it is not
always easy to do the right thing in a given circumstance because the right choice
may not always benefit the hygienist’s best interests.

Dental professionals, including dental hygienists, are confronted daily with

difficult choices that require decisive action and judgment calls for which careful
deliberation is required.4 To enable a fair consideration for all parties, certain
guidelines or health-care principles are available to “weigh the potential
consequences (benefits and harm) and the rights and general welfare of all
involved.”4 The four principles of health-care ethics are autonomy, beneficence,
nonmaleficence, and justice5 (see chart 1). “Beneficence and nonmaleficence are
often linked because both are found in the Hippocratic tradition, which requires
the physician [dentist or hygienist] to do what will best benefit the patient.”1 It
is important for the dental hygienist to consider all four ethical principles when
weighing a moral dilemma regarding patients.

An ethical dilemma occurs when one of the above principles conflicts with another.1
For example, a patient decides he or she wants to save money by refusing X-rays for
the fourth year in a row. The patient is exercising his or her autonomy. However,
the hygienist realizes this puts him or her in an ethical dilemma. Not taking X-
rays for so long is a form of nonmaleficence, and it does not benefit the patient
and can harm the patient due to undetected periodontal disease, decay, pathology,
and more.

Practicing in the dental profession, dental hygienists see an array of ethical

concerns while treating patients. These dilemmas can vary depending on the type of
practice, specialty, and age of patients in the practice. However, there are some
ethical areas that are more common and will be highlighted here. The specific case
examples that follow relate to the ethical principles presented in chart 1, and
values that correspond to these principles in our profession.

Paternalism vs. informed consent

Paternalism is the practice of acting as the “parent,” which is taking it upon
oneself to make decisions for the patient. Years ago the “doctor knows best”
approach regarding treatment was common. The doctor merely picked a course of
treatment he or she thought was best for the patient. Of course, paternalism is not
acceptable today because it eliminates patients’ right to choose the treatment they
feel is right for them, even if their choice is not what the doctor feels is best.

Here is an example of paternalism. The patient is given a treatment plan of

extracting a painful tooth and fabricating a three-unit bridge for tooth
replacement. Due to the patient’s age, the dentist feels this is the easiest
approach so the tooth will not give the patient any problems in the future. In this
case, there is no mention of possible endodontic treatment or replacing the
extracted tooth (if extraction is required) with an implant. Paternalism violates
this patient’s autonomy and self-determination, and ethically involves
nonmaleficence due to not giving the patient the right to informed consent; thus,
paternalism is the opposite of informed consent. This patient did not have all the
information needed to make an informed decision for care.

Informed consent is highly recommended for today’s progressive medical and