Karen E. Faith BSW,MEd,MSc,RSW Ethics Consultant & Educator kefaith@rogers

1. Ethics and Cosmetic Dentistry: Beneficence, beauty or “bucks”?Toronto Academy of Dentistry Friday Nov. 12, 2010 Karen E. Faith BSW,MEd,MSc,RSW Ethics Consultant & Educator kefaith@rogers.com

2. Outline • Ethics 101 • Ethical considerations re: cosmetic procedures • Key ethical challenges for dentistry • Value-centered practice and questions for ethical reflection

3. Hippocrates, the Oath I will follow that system or regimen which according to my ability and judgment I consider for the benefit of my patient and abstain from whatever is deleterious and mischievous.

4. Health Care “health care”: provision of assistance to persons in need of care, cure, education, prevention, or help related to trauma, illness, disability or dysfunction by other persons knowledgeable and skillful in providing such assistance. Journal of Medicine and Philosophy, 1999, Vol. 24, No. 3, pp. 243-266 (Pellegrino)

5. Dentistry Dentistry as a profession is “based in service, in preventing and treating disease, and in restoring health.” Simonsen, 2007

6. Cosmetic Dentistry

7. What is bioethics? • Bioethics involves critical reflection on moral/ethical problems faced in health care settings toward: • deciding what we should do • explaining why we should do it and • describing how we should do it • (Dr Barb Secker)

8. Traditional Principlism • Autonomy • Beneficence • Non-maleficence • Justice

9. RCDS of Ontario Core Values • Autonomy • Beneficence • Compassion • Fairness • Integrity

10. Autonomy The right of a competent person to make informed decisions regarding his/her health options. “Understanding and respecting patients’ rights to make informed decisions based on personal values and beliefs.” RCDS Code of Ethics

11. Traditional View of Autonomy • Autonomy • Individualism • Contractual nature of helping relationships • Right to make an ill- advised decision • People have experience & skills in exercising autonomy • There are choices through which to exercise autonomy

12. Beneficence “ Every act and every inquiry, and similarly every action and pursuit is thought to aim at some good and for this reason the good has rightly been declared to be that which all things aim.” Aristotle, Nicomachean Ethics, 1094a 1-3 “Maximizing benefits and minimizing harm for the welfare of the patient” RCDS Code of Ethics

13. Non MaleficenceBlair Henry • Do no harm or allow harm to happen • What are the provider’s biases? • What can be done to protect the patient? • Would the action cause harm or make the patient worse? • What negative outcomes are possible with and without action?

14. Justice • Balancing the rights and well-being of the individual with the rights and well-being of others • Broader societal considerations in distribution of scarce health resources • Laws • Health Policy • Public health

15. Just access to comprehensive dental care

16. Why ethics matter

17. Evolution of goals/values We are faced with a balancing act between fidelity to the moral wisdom of the past and responsive adaptation to the circumstances of the present. Miller & Brody, 2001

18. Just because we can do it, ought we do it? October 20, 2009|Kimi Yoshino The Beverly Hills fertility doctor who treated octuplets mom NadyaSuleman has been expelled from the American Society of Reproductive Medicine for a "pattern of behavior" detrimental to the industry, a spokesman for the association confirmed Monday. Los Angeles Times

19. What is the potential for conflict of interests? • Dentist as health practitioner and… • Dentist as business manager/entrepreneur and… • Dentist as purveyor of beauty enhancement procedures

20. Overtreatment or Good Clinical/Esthetic Outcome?

21. What is healthy? What is normal?Does it matter? UK Chic Hollywood update

22. What is normal? What is healthy?Does it matter? Some ethicists, philosophers and policy makers are urging a reorientation of the physician’s beneficence from an exclusive focus on the good of individual patients to a focus on societal good. Pellegrino, 2001

23. Are dental services a commodity? Is health care (dental care) sufficiently different from pantyhose, ocean-front condominiums, or television sets to set it apart from other consumer goods? • Journal of Medicine and Philosophy, 1999, Vol. 24, No. 3, pp. 243-266 (Pellegrino)

24. Are dental services a commodity?

25. Culture, context & commodities • Commodities may be used in the process of providing care, but the totality of health care itself is not a commodity. • Journal of Medicine and Philosophy, 1999, Vol. 24, No. 3, pp. 243-266 (Pellegrino)

26. Sticking with core values

27. Professionalism, Standards & Accountabilities • Maintaining core values of dentistry: Health promotion- disease prevention • Critical analysis of market driven incentives to offer cosmetic procedures • Where is the ethical tipping point between professionalism and overtreatment? • Promoting ethics in daily practice • Joint accountabilities: ethical implications regarding cosmetic enhancement procedures

28. Key questions for ethical practice • What are my motives in offering this cosmetic option to my patient? Are these motives consistent with primary clinical and ethical duties to promote health and prevent disease? • Am I qualified and proficient (training and experience) to offer this cosmetic procedure? • Have I sufficiently addressed any COI in offering these treatments to my patient?

29. Key questions for ethical practice • What personal/cultural bias on gender, beauty etc informs the way I am assessing my patient’s oral health and/or appearance? • Has the information shared with the patient included short-term, long-term and perhaps yet to be discovered risks? • Is the level of risk ethically acceptable/defensible given the likely health benefits to the patient? • Do I have a means through which to address the “yuk’ factor (ethical uncertainty) in my work?

30. Discussion