ETHICS IN CLINICAL PRACTICE

1. ETHICS IN CLINICAL PRACTICE

2. Introduction • Dentistry has long prided itself on being a profession. • The dental profession holds a special position of trust within society. As a consequence, society affords the profession certain privileges that are not available to members of the public-at-large.

3. The profession has special obligation like observing their duties, being service oriented rather than profit oriented, maintaining interpersonal relationship which may include making decisions between right and wrong. • Ethics may be considered as the hills of help for modern man. “Ethics warms the heart and cools the mind”

4. Ethics • Greek word ethos- custom • Latin word for custom- mores • Ethics is a branch of philosophy which deals with the examination of human conduct • Ethics- moral philosophy

5. Definition of Ethics • Is defined as "the science of the ideal human character and behavior in situations where distinction must be made between right and wrong, duty must be followed and good interpersonal relations maintained".

6. Professional Ethics: It is the code by which it regulates actions and sets standards for its members

7. “It would not be correct to say that every moral obligation involves a legal duty; but every legal duty is founded on a moral obligation”. Lord Chief Justice Coleridge (1893)

8. Evolution of Medical ethics

9. Egyptian medicine • Rigid rules were laid down as to experimental treatment - there was no culpability in failure to cure so long as the standard text book were followed • Severe penalties, were, however, threatened for those who ignore the instructions, the reason being that very few men would be expected to know better than the best specialist who had gone before.

10. Babylonian Medicine The code of Hammurabi (c 1900BC) – the first known legal code. It contained • An element of Medical ethics • A system of payment based on result and, to some extent, on the ability to pay and on the status of the patient • Penalties for negligent failure, some of which were draconian to an extent which must have deterred many from entering the profession.

11. Greek Medicine • A code of intra-professional conduct evolved-the dawn of what has become known as medical etiquette. • Hippocratic oath

12. Hippocratic oath • Implies the need for co-ordinated instruction and registration of doctors, the public is to be protected, so for as is possible, from the dabbler or the charlatan • It is clearly stated that the doctor is there for the benefit of his patient – to the best of his ability he must do them good and nothing which he knows will cause harm

13. Hippocratic oath • The nature of the doctor and patient relationship is outlined and an undertaking is given not to take advantage of that relationship • Oath expresses the doctrine of medical confidentiality

14. Dentist has the duty to conduct his / her professional life in accordance with the principles rooted in the moral rules “ ETHICAL PRINCIPLES”

15. Ethical Principles • To do no harm (non- maleficence) • To do good (Beneficence) • Respect for persons • Justice • Veracity or truthfulness • Confidentiality

16. To do no harm (Non-Maleficence) • It is generally attributed to Hippocrates. It is considered to be the foundation of social morality. • ‘Primum non nocere’ – First do no harm. • Not being negligent towards patient. • For example : Iatrogenic diseases.

17. To do good (Beneficence) • It should be the role of dentists and dental hygienists to benefit patients, as well as not to inflict harm. • The expectation of the patient is that the care provider will initiate beneficial action and that there is an agreement between the doctor and patient that some good will occur.

18. In the process of treating a patient what has to be weighed are the consequences of treatment versus no treatment, e.g.: questionable dental caries. • The attempts should be to maximize the benefits and minimize harm.

19. Respect for persons • This incorporates at least two other ethical principles of which autonomy dictates that health care professionals respect the patients capacity for self determination in making decision regarding their treatment and informed consent is an essential component of a patient’s right to autonomy.

20. Autonomy • The primary way to respect individuals is to abide by their choices whether others believe these choices to be wise or beneficial. • Autonomy is a principle that dictates that health care professionals respect the patient’s right to make decisions concerning the treatment plan.

21. Doctor-Patient Relationship Models • 1. Guide model • 2. Agent model • 3. Commercial model • 4. Interactive model

22. Interactive Model: • Dentist and patient are equal partners • Preservation and maximization of patient autonomy • Dentist enhances patient's decision making capacity • Dentist contributes expertise into the decision-making process

23. Dentists are seen as a paternalistic figure and Paternalism in health care can take the form of withholding information, restricting choices, or making the choice for the patient.

24. Informed consent • Informed consent, both a legal and an ethical concept, is an essential component of a patient’s right to autonomy.

25. Consent should not be obtained with bribery, or misinformation. If a person cannot give informed consent it is desirable to obtain proxy consent.

26. The informed consent is a two step process • First information is presented to the subject by the professional. • Secondly, the subject satisfies himself or herself that he or she understands and based upon this understanding either agrees or refuses treatment

27. Justice • The primary duty of the health professional is service irrespective of class, creed etc. • Justice demands that each person be treated equally. • It calls for an obligation to protect the weak and to ensure equity in rights and benefits, both for groups and individuals.

28. It thrives for universal coverage and for care according to need. • The principle of justice in relation to health care calls for community participation in decisions and care which is effective and affordable.

29. Truthfulness • The patient – doctor relationship is based on trust. • Lying shows disrespect to the patient and threatens relationship. • Studies in 1950 and 1960 (on terminally ill patients) had shown that the physicians had the right, indeed duty to withhold bad news when they believed it would upset the patient.

30. It is an example for Hippocratic paternalism, that is, the doctor knows the best. Nowadays, in certain areas, there is a reversal of this dominant physician pattern.

31. Confidentiality • Is a principle that can be traced to the Hippocratic Oath and exists today in the International Code of Medical Ethics. • Every patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential. • It is very natural to want to gossip about a patient, but to do so would break a bond of trust between dental professional and patient.

32. Earlier it was widely accepted that confidentiality could be breached if it was thought it would benefit the patient. • Now patient’s permission has to be sought. • In no instance other than in the court of law or the patient changes the dentist, should confidentiality be breached.

33. The Indian Scenario • ‘Ethical rules for Dentists’ were initially formed by the DCI, and the Dentist Act was amended via section 17A. • The code of ethics was framed by the Dental Council in 1975 and later notified by the Government of India as Dentists Regulations 1976. • It is in force from August 1976.

34. Ethical Rules for Dentists (Prescribed by the DCI) • The duties and obligations of dentist towards the patients: • Every dentist should be courteous, sympathetic, friendly and helpful. • He should be punctual in fulfilling his appointments. • He should establish a well merited reputation for professional ability.

35. The welfare of the patient should be conserved to the utmost of the practitioners ability. • A dentist should not permit consideration of religion, nationality, race, party politics to intervene between his duties and his patients. • Information of a personal nature, which may be learned about or directly from a patient in the course of dental practice, should be kept in utmost confidence.

36. Duties of Dentist Towards One Another • Every dentist should cherish a proper pride in his/her colleagues and should not disparage them either by act or word. • When the dentist is entrusted with the care of the patient of another, during sickness or absence, mutual arrangement should be made regarding remuneration.

37. 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 and in such a manner as to avoid reflection on his predecessor. • A dentist called upon in any emergency to treat the patient of another dentist, should when the emergency is provided for, retire in favor of regular or but shall be entitled to charge patient for his services.

38. Duties of the Dentist to the Public: Police and Law courts • A dentist is not bound to disclose professional secrets unless called upon by the magistrate or judge to do so. • Knowledge of a patient gained in the course of examination and treatment is privileged and should not be disclosed without the consent of the patient or an order from the presiding judge in a court of law.

39. Accepted measures to improve the general and dental health of the public should be promoted by the dentist. • Dentists may only advance their professional reputation through professional services to the patients and to society.

40. WHAT WOULD YOU DO IN THE FOLLOWING SITUATIONS???? CASE 1: 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. But the dentist attending the case insists on composite restoration . The principle of ethics violated here is ???? Autonomy

41. CASE 2: Fresh General dentist with limited surgical skills considers performing a biopsy herself rather than referring the patient to an oral and maxillofacial specialist. Here the extent of tissue removed , the skills of procedure may vary when done by the fresher compared to that of specialist The principle of ethics violated here is ???? Non-maleficence

42. CASE 3: • Dr Vimal clinically examines Mr Shankar and finds his oral signs and symptoms similar to that those find in HIV positives hence advices the patient for confirmatory test and finds the patient is HIV+ • He rejects to treat the patient, and sends him back with out attending him so the principle of ethics lost here is ?????? Beneficence

43. He also discloses the fact that Mr Shankar is HIV+ to his other patients and their relatives present in his clinic … so the principle of ethics lost here is ?????????????????????? Confidentiality

44. Conclusion • Unethical decision lead to unethical conduct which seriously compromises the services to the patients and undermines ones ability to function as a professionals. Hence without a solid ethical foundation one cannot be a true professional.

45. Bibliography • Ozar/ Sokol, Dental ethics at chairside: professional principles and practical applications, 1994 • Ethics Handbook for Dentists, Introduction to Ethics, Professionalism, and Ethical Decision Making • Burt B. A, Eklund S. A. Dentistry, dental practice, and the community, • Gilbier S, Wright D, Bishop M. Ethics and Dentistry: The meaning of ethics. Dent Update 2001; 28: 468-73. • Basic Information on Ethics in Dentistry: What All Dentists Should Know • Peter S. Essentials of preventive and community dentistry, 3rd edition, Arya publishing house. • www.google.com