Ethics in Dentistry

DDS. Mariam Khardziani

Invited Lecturer
Department of Medicine
Ivane Javakhishvili Tbilisi State University
Content

 Origin and Definition

 History - Hippocratic Oath
 Nuremberg Code
 Ethical Principles
 Obligations of dentist to patients
 Obligations of dentists to colleagues
 Obligations of dentists to society
 Helsinki Declaration
 Conclusion
Origin and Definition

 The world ethics is derived from the Greek word ‘ethos’ meaning
custom or character.
 Ethics is the philosophy of human conduct.
 "the science of the ideal human character and behaviour in
situations where distinction must be made between right and
wrong, duty must be followed and good interpersonal relations
maintained".
History

 Hippocratic Oath written by Hippocrates, the father of medicine in 4th

century BC.
 Highlights

“I will prescribe regimens for the good of my patients and never do harm to
anyone, I will not prescribe deadly drugs. I will not cut for stone; I will leave
operations to be performed by specialists. All that may come to my knowledge in
the exercise of my profession I will keep secret and not reveal.”
Hippocrates Oath

 I swear to fulfill, to the best of my ability and judgment, this covenant:

 I will respect the hard-won scientific gains of those physicians in whose steps I
walk, and gladly share such knowledge as is mine with those who are to follow.
 I will apply, for the benefit of the sick, all measures [that] are required, avoiding
those twin traps of overtreatment and therapeutic nihilism.
 I will remember that there is art to medicine as well as science, and that
warmth, sympathy, and understanding may outweigh the surgeon's knife or the
chemist's drug.
 I will not be ashamed to say "I know not", nor will I fail to call in my colleagues
when the skills of another are needed for a patient's recovery.
Hippocrated oath

 I will respect the privacy of my patients, for their problems are not disclosed to me that the
world may know. Most especially must I tread with care in matters of life and death. If it is
given me to save a life, all thanks. But it may also be within my power to take a life; this
awesome responsibility must be faced with great humbleness and awareness of my own
frailty. Above all, I must not play at God.
 I will remember that I do not treat a fever chart, a cancerous growth, but a sick human
being, whose illness may affect the person's family and economic stability. My responsibility
includes these related problems, if I am to care adequately for the sick.
 I will prevent disease whenever I can, for prevention is preferable to cure.
 I will remember that I remain a member of society, with special obligations to all my fellow
human beings, those sound of mind and body as well as the infirm.
 If I do not violate this oath, may I enjoy life and art, respected while I live and remembered
with affection thereafter. May I always act so as to preserve the finest traditions of my
calling and may I long experience the joy of healing those who seek my help.
Nuremberg Code 1947

 Set of research ethical principles for human experimentation set as a result of

Nuremberg Trials at the end of the Second World War.
 They were created in response to the inhumane Nazi experiments on
prisoners during second world war.

Sulfonamide experiments
Subjects were deliberately wounded on the outer side of their
calves. Physicians then rubbed a mixture of bacteria into the open
wounds before sewing them shut.
Nuremberg code

1. The voluntary consent of the human subject is absolutely essential. This means that the
person involved should have legal capacity to give consent; should be so situated as to
be able to exercise free power of choice, without the intervention of any element of force,
fraud, deceit, duress, overreaching, or other ulterior form of constraint or coercion; and
should have sufficient knowledge and comprehension of the elements of the subject
matter involved as to enable him to make an understanding and enlightened decision.
This latter element requires that before the acceptance of an affirmative decision by the
experimental subject there should be made known to him the nature, duration, and
purpose of the experiment; the method and means by which it is to be conducted; all
inconveniences and hazards reasonably to be expected; and the effects upon his health
or person which may possibly come from his participation in the experiment. The duty and
responsibility for ascertaining the quality of the consent rests upon each individual who
initiates, directs, or engages in the experiment. It is a personal duty and responsibility
which may not be delegated to another with impunity.[13]
2. The experiment should be such as to yield fruitful results for the good of society,
unprocurable by other methods or means of study, and not random and unnecessary in
nature.
Nuremberg Code

3.The experiment should be so designed and based on the results of animal experimentation
and a knowledge of the natural history of the disease or other problem under study that the
anticipated results will justify the performance of the experiment.
4. The experiment should be so conducted as to avoid all unnecessary physical and mental
suffering and injury.
5. No experiment should be conducted where there is an a priori reason to believe that
death or disabling injury will occur; except, perhaps, in those experiments where the
experimental physicians also serve as subjects.
6. The degree of risk to be taken should never exceed that determined by the humanitarian
importance of the problem to be solved by the experiment.
7. Proper preparations should be made and adequate facilities provided to protect the
experimental subject against even remote possibilities of injury, disability, or death.
8. The experiment should be conducted only by scientifically qualified persons. The highest
degree of skill and care should be required through all stages of the experiment of those
who conduct or engage in the experiment.
Nuremberg code

9. During the course of the experiment the human subject should be at liberty to bring the
experiment to an end if he has reached the physical or mental state where continuation of
the experiment seems to him to be impossible.
10. During the course of the experiment the scientist in charge must be prepared to
terminate the experiment at any stage, if he has probable cause to believe, in the exercise
of the good faith, superior skill and careful judgment required of him that a continuation
of the experiment is likely to result in injury, disability, or death to the experimental
subject.
Principles of ethics

 Non-maleficence
 Beneficence
 Respect for persons
 Justice
 Veracity
 Confidentiality
To Do No Harm (Non-maleficence)

 Hippocrates, pioneer in Greek medicine has laid an emphasis on non-

maleficence or to do no harm.
 As per this, the first and foremost duty of the health care professional is to
ensure that his actions do not harm the patient in any way.
 Use of unsterilized instruments, under filling or overfilling, carelessness in
handling hard and soft tissues of the mouth are some of the instances, which
can harm the patients.
To Do Good (Beneficience)

 The health care professional, before instituting any

action or care should question himself whether such
actions will help the patient to recover or to perform
his functions better or not.
 He has to place the interest of the patient above his
own interest.
 He has to plan a treatment or order an investigation
only if it is necessary.
 In the process of treating a patient –weigh the
consequences of treatment Vs no treatment.
 E.g. in questionable dental caries - the attempts should
be to maximize the benefits and minimize the harm.
Respect for people

 Incorporates two other ethical principles:

 1. Autonomy
 2. Informed consent
Autonomy

 This principle is in line with interactive model of health

care wherein patient is the prominent member in the
process of decision making.
 This principle emphasizes the patient's right to make
decisions and is free to determine what will happen on
his/her body.
 A patient is diagnosed with dental caries in relation to
46 and 36. The treatment of choice which could be
given here are silver amalgam , GIC, composites.
However, the dentist attending the case insists on a
composite restoration.
Informed consent

 The health care professional has to ensure that consent

is obtained before any care is instituted.
 Patients are provided with relevant information such
as different modes of treatment, their risks and
benefits consequences of not availing the treatment
etc.
 Information given should be easily understood
facilitating the patient to make a voluntary consent.
 In case of minors, parents or legal guardians can grant
the consent for the care.
Justice

 This principle directs health care professional to provide equal

treatment to all, giving to each patient what he/she needs.
 Dental practitioners are often found to be reluctant to treat the poor
because they cannot afford; treat the children or mentally retarded
because it takes longer time.
 Dentists also have responsibilities for such group of patients and
cannot shy away from the responsibilities bestowed on them by the
society.
 Dentists probably can provide care at a concessional rate or
designate certain time for the care of such patients or support
programmes for such patients conducted by local, regional or state
bodies.
Veracity
 Patient-doctor relationship is based on mutual trust.
 Patients expect the dentist to be truthful about the
information given, treatment rendered, and the prognosis.
 Even if the dentist believes lying or concealing or
manipulation of the information is required in the best
interest of the patient, the relationship is bound to suffer.
 The dentist may feel that it would be better if the patient
took certain course of action and therefore manipulates the
information that is given to the patient. Whatever the
reason, the relationship will suffer and the dentist will be
guilty of transgressing a major ethical principle.
 Mr. Y comes to the dental clinic complaining of pain in lower
right back tooth (46). The dentist tells the patient that an RCT
has to be done. And the patient agrees for the same. While
doing the RCT the dentist happens to breaks a file in the canal
which he is not able to retrieve. But he does not tell the
patient about it. After the treatment, the patient returns with
pain in the teeth after 6 months. The dentist says there is
infection in the canal and that the tooth cannot be saved and
that it has to be extracted.
Confidentiality

 Patients have the right to expect that all communications and

records pertaining to their care will be treated as
confidential.
 Gossiping/discussing about patient (some famous
patient/neighbor) would break a bond of trust between
dental professional and patient.
 Now, patients permission has to be sought to disclose
the confidentiality, even if it is beneficial to the patient.
Obligations towards Patients

 Every dentist should be courteous, sympathetic, friendly and helpful.

 He should observe punctuality in fulfilling his appointments.
 He should establish a well merited reputation for professional ability
and fidelity.
 The welfare of patient should be conserved to the utmost of the
practitioner’s ability.
 A dentist should not permit considerations of religion, nationality,
race, party politics or social standing to intervene between his duties
and his patients.
 Information of personal nature which may be learned about or directly
from a patient in the course of dental practice should be kept in utmost
confidence. It is also obligation of the dentist to see that his auxiliary
staff observed this rule.
Obligations towards Professional
Colleagues
 Every dentist should cherish a proper pride in his/her colleagues
and should not disparage them either by act or word.
 Mutual arrangements should be made regarding remuneration,
when other dentist’s patient is taken care in his
sickness/absence.
 If a dentist is called for providing emergencies, he should retire
after it is over (in favor of the regular dentist), but is entitled to
charge the patient for his services.
 If a dentist is consulted by the patient of another dentist and the
former finds that the patient is suffering from previous faulty
treatment it is his duty to institute correct treatment at once
with as little comments as possible and in such a manner as to
avoid reflection on his predecessor.
Duties towards Society

 The dentist has to assume leadership in the

community on matters pertaining to dental health.
 People should be urged to seek care without influencing
the choice of dentist.
Unethical Practices

 Unregistered persons
 Advertising
 Undercutting charges to solicit patients
 Accepting or paying commission
 Use of bogus diploma
 Unethical practices
 Not referring the patient to the consultant if the
planned treatment is beyond the skills of the dentist.
 Emergency consultation, not sending the patient back
to previous care provider
Helsinki Declaration

 Recommendations guiding physicians in biomedical

research involving human subjects.
 Issued by World Medical Association in 1964 in Helsinki, Finland
General Principles of Helsinki
Declaration
 The Declaration of Geneva of the WMA binds the physician with the words, “The health of my patient
will be my first consideration,” and the International Code of Medical Ethics declares that, “A physician
shall act in the patient’s best interest when providing medical care.”
 It is the duty of the physician to promote and safeguard the health, well-being and rights of patients,
including those who are involved in medical research. The physician’s knowledge and conscience are
dedicated to the fulfilment of this duty.
 Medical progress is based on research that ultimately must include studies involving human subjects.
 The primary purpose of medical research involving human subjects is to understand the causes,
development and effects of diseases and improve preventive, diagnostic and therapeutic interventions
(methods, procedures and treatments). Even the best proven interventions must be evaluated
continually through research for their safety, effectiveness, efficiency, accessibility and quality.
 Medical research is subject to ethical standards that promote and ensure respect for all human subjects
and protect their health and rights.
 While the primary purpose of medical research is to generate new knowledge, this goal can never take
precedence over the rights and interests of individual research subjects.
General Principles of Helsinki
Declaration
 It is the duty of physicians who are involved in medical research to protect the life, health, dignity, integrity,
right to self-determination, privacy, and confidentiality of personal information of research subjects. The
responsibility for the protection of research subjects must always rest with the physician or other health care
professionals and never with the research subjects, even though they have given consent.
 Physicians must consider the ethical, legal and regulatory norms and standards for research involving human
subjects in their own countries as well as applicable international norms and standards. No national or international
ethical, legal or regulatory requirement should reduce or eliminate any of the protections for research subjects set
forth in this Declaration.
 Medical research should be conducted in a manner that minimises possible harm to the environment.
 Medical research involving human subjects must be conducted only by individuals with the appropriate ethics
and scientific education, training and qualifications. Research on patients or healthy volunteers requires the
supervision of a competent and appropriately qualified physician or other health care professional.
 Groups that are underrepresented in medical research should be provided appropriate access to participation
in research.
 Physicians who combine medical research with medical care should involve their patients in research only to
the extent that this is justified by its potential preventive, diagnostic or therapeutic value and if the physician
has good reason to believe that participation in the research study will not adversely affect the health of the
patients who serve as research subjects.
 Appropriate compensation and treatment for subjects who are harmed as a result of participating in research
must be ensured.
THANK YOU!