Principles and theory of Ethics

Dr. Shahistha Parveen Dasnadi

MDS, Ph.D
Post Graduate Diploma in Bio Ethics and Medical Ethics
Post Graduate Diploma in Clinical Ethics
Assistant Professor
RAKCODS, Rasal Khaimah, UAE
Course Learning outcomes

• Outline ethics and professionalism and their role in dental practice

 Content- Principles of Ethics
1. Autonomy

2. Beneficence

3. Nonmalificence

4. Justice

5. Veracity

6. Fidelity

7. Confidentiality
Bioethics, medical ethics and clinical ethics is based on Four principles.

Tom Beauchamp and James Childress developed a

new approach to ethical decision making in their
1977 book, Principles of Biomedical Ethics. This
approach has four principles and known as “
Principalism” and are as follows

1. Respect for Autonomy

2. Beneficence

3. Non- malificence

4. Justice.
 1. Respect for Autonomy

Autonomy: It is a person's ability to make decisions based on his or her own needs,
desires, or judgments

• Autonomy is the basis of informed consent, which enables patients to accept or decline
treatment for themselves

• When the patient is minor (below 18 years) consent should be given by the parent

• The concept of Joint autonomy involves concerns of both the parents and the child
 1. Respect for Autonomy
Our Title as Doctors is derived from the Latin word Doctus, meaning teacher

Doctus stems from the Latin word docere, which means “to teach.” As doctors, our
responsibility as teachers of our patients is paramount.

A. Patient Involvement. 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. Respect for Autonomy

Under this principle, the dentist’s primary obligations include involving patients in
treatment decisions in a meaningful way with due consideration being given to the
patient’s needs, desires and abilities, and safeguarding the patient’s privacy
 1. Respect for Autonomy

• However, this concept of autonomy sometimes puts the dentist in an ethical

dilemma when it involves the patients who are minors

• In such cases, the autonomy of the parent should override that of the minor

• Autonomy is also considered as the basis of informed consent, which enables

patients to accept or decline treatment for themselves.
 Non-autonomous /partially autonomous patients

These are people incapable of making autonomous decisions and are not given the right
to make autonomous decisions, such as:

• Mentally challenged

• Children below 12 years, although by the age of 8 years they are partly autonomous
as can understand the benefit of treatment
 Informed consent
• Consent is a decision of a competent patient to accept the medical procedures
proposed. The patient has the right to refuse the proposed treatment

• Both consent and refusal must be informed, i.e., based on full disclosure of the
details of the proposed treatment, including its benefits and risks

• Children with some degree of competence can assent to treatment, which

signifies their agreement with what their parents, their legal decision makers,
have decided

• Parents may assent to the decision of a fully competent post-pubertal child who
is below the age of majority, currently 18 years in Saudi Arabia.
 Informed Refusal

• The principle of autonomy sometimes conflicts with other principles and values

• Various reasons like previous experiences, prejudices, religious beliefs, cultural lore,
financial limitations, phobias, or simply a whim might be sufficient for a patient to reject
the ideal option and choose a significantly compromised alternative

• Though a dentist must be introspective to be certain that the risks, benefits and options
were explained clearly and thoroughly in non-prejudicial, lay terms. However, the
practitioner has full Autonomy to refuse to provide therapy if the limitations
imposed by the patient might jeopardize his or her dental health.
 Informed Refusal

For example:

A patient prefers the extraction of her last 10 maxillary teeth and the
construction of a denture

If the patient is adequately informed about the importance of retaining the

natural dentition, the decision is autonomous although it does not promote her
well being

The dentist can refused to treat the patient under informed refusal
 Case scenario 1: Autonomy as the basis of informed consent

An 80-year-old, fully conscious, and competent man with advanced incurable

cancer needed palliative chemotherapy. The family objected when the doctor
wanted to obtain informed consent from the patient because that would involve
disclosing the diagnosis, which would make the patient very sad and depressed. The
family wanted to make the decision without informing the patient. What should
the doctor do? Provide your moral reasoning.
• The doctor should respect the patient’s autonomy.

• He should first ask the patient if he personally wanted to receive information about
his condition in order to make decisions on his treatment, or whether he would
prefer that the information be disclosed to his family, and the family authorized to
make decisions on his behalf

• If he insists on making decisions for himself, he must receive full disclosure and
exercise his autonomous right to informed consent

• If he chooses to leave everything to the family, the doctor can deal with the family
accordingly.
 Case scenario 2: Scope and limitations of consent

A 30-year-old woman presented with classical signs of acute appendicitis. She

consented to an operation to open the abdomen and remove the inflamed
appendix. The surgeon found a previously undiagnosed ovarian cyst and decided
to remove it. The removal was a simple and safe procedure that would not have
increased the duration of the operation. The head nurse refused because the
patient had not given consent. What should the surgeon do? Provide your moral
reasoning
 Paternalism

Pater: Father, the family decider

• A behavior, by a person, organization which

Limits some person or group's liberty or

Autonomy for their own good

• It is the antithesis of the concept of autonomy

and is not acceptable approach

Paradigm shift

Doctor-patient relationship/ Doctor centric To Provider-client

Relationship/Patient Centric
 Why does paternalism occur?

 Clinicians know ‘better’; superior technical knowledge

 Physician’s intentions are noble

 Patient can’t decide for himself

 An ill patient is vulnerable; suboptimal mental clarity

 Emotionally disturbed

 Societal influence
 2. Beneficence

Guides one to do what is good

• The doctor’s first and foremost duty is to do good to the patient by offering the best
available treatment.

• As professionals, we should place the well-being of patients ahead of our own personal
gain.
 2. Beneficence

• Under this principle, the dentist’s primary obligation is service to the patient and
the public-at-large

• The most important aspect of this obligation is the competent and timely
delivery of dental care within the bounds of clinical circumstances presented
by the patient, with due consideration being given to the needs, desires and
values of the patient

• The same ethical considerations apply whether the dentist engages in fee-for-
service, managed care or some other practice arrangement
 3. Non- maleficence

Is do no harm to the patient.

It is a duty of medical professionals to refer a patient to

a senior colleague or specialist if one is unable to treat.

Some examples of nonmaleficence are:

• When a general dentist with limited surgical skills considers performing a biopsy herself rather

than referring the patient to an oral surgeon.

• An oral surgeon attempts at removing a squamous cell carcinoma of the skin causing a scar.

Instead of referring him to a plastic surgeon

• All these examples involve issues of concern for harming the patients in one way or an other
 This concept is broad and involves 2 different aspects:

1. Enhancing the welfare of others through acts that extends from doing no harm to the

prevention and removal of harm and doing the good

2. Involves the balancing of benefits against harms

The nature of the balancing process requires the patient’s

values and viewpoints be taken into consideration.

Example: Injection of local anesthesia to avoid the larger pain of cavity reparation.
 4. Justice

Is defined as a form of fairness

The principle of justice has to do with three closely related ideas:

1. Treating people fairly

2. Giving people what they deserve

3. Giving people to which they are entitled

Aristotle: “Giving to each that which is his due”

• Persons who are equals should qualify for equal treatment.

• For eg. All below 65 qualify for health insurance

 Types of Justice

1. Distributive (fairness justice): Fair share- resources should be given first

to those who need it the most

2. Procedural: Fair play, process is fair, equal distribution to everyone

regardless of need

3. Restorative: Compensation, resources should be given first to those who

need it the most, Simplest form –an apology

4. Retributive: Principle of punishment

 4. Justice

This principle expresses the concept that professionals have a duty to be fair in
their dealings with patients, colleagues and society
• Under this principle, the dentist’s primary obligations include dealing with people
justly and delivering dental care without prejudice
• Dentists shall not refuse to accept patients into their practice or deny dental service
to patients because of the patient’s race, color, gender, national origin or disability
 What is the difference ?

Equality= All humans having the Equity= The application of the principle
of fairness in practice
same rights and status in theory

I believe everyone should be equal I am going to make sure I treat everyone

the same
 Distributive justice

In managing the issues of societal distribution of benefits and burdens, the

term distributive justice is used.

• It pertains to just allocation of many different aspects of life that include

voting rights, salaries, taxes, rights of minorities, rights of women, health care
etc.

• Distributive justice tries to link interests, ambitions and capabilities and how
society should distribute its benefits and obligations.
 When to say no for patient treatment

• Members may exercise discretion in selecting a patient into their practice, provided they
shall not refuse to accept the patient because of the patient’s race, creed, color, sex,
national origin, disability, HIV seropositivity status or other legally recognized
protected class”

• It also would be unwise to reject a patient from your private practice if the reason for your
rejection is solely based on discrimination, including any of the reasons listed above in
the AAO code

• From an ethical perspective, your decision to decline a patient for care must be based on
incompetency to treat the particular illness

• You should offer assistance in identifying a possible alternative provider

 5. Veracity

• Telling the truth whether it will help or hurt the patient

• It is concerned with being open, honest and truthful with people

• This principle expresses the concept that professionals have a duty to be honest and
trustworthy in their dealings with people

• It is also the accurate transfer of information in a way that is suitable for the
individual to understand
 5. Veracity (“Truthfulness”).

• The dentist has a duty to communicate truthfully

• Under this principle, the dentist’s primary obligations include respecting the position of
trust inherent in the dentist-patient relationship, communicating truthfully and without
deception, and maintaining intellectual integrity

• Clinicians began to recognize the need for a child's Trust and co-operation in promoting
favorable outcomes in recovery

*** Disclosure of the truth was seen as upholding the ethical principle of veracity. Yet the
absence of disclosure is not the equivalent of a lie and sometimes might be warranted
Veracity in dental health insurance

Treatment Dates. A dentist who submits a claim form, reporting incorrect

treatment dates for the purpose of obtaining benefits under a dental plan, is
unethical

Dental Procedures. A dentist who incorrectly describes on a third party,

makes a non-covered procedure appear to be a covered procedure on a
claim form is unethical
 6. Fidelity

Fidelity is about: keeping promises and other commitment. It the foundation for the
duty of confidentiality
• Being faithful

• Doing what is right

• Showing respect

• Acting in their best interest

• The patient's “blind faith” in the skills and goodwill of the doctor, coupled with the
doctor's superior knowledge of his or her specialty, places the patient in a position of
high vulnerability. The patient trusts that his or her interests and needs will surpass the
doctor's in treatment delivery
 7. Privacy

• To respect privacy of information and action

*** Ethically, there are issues related to the duty of doctors not to harm their patients and
to strive to do good for them

• Breaching people’s privacy and disclosing their medical information irresponsibly

is considered to be professional misconduct, which might cause psychological, social,
and sometimes physical harm to the patient which may extend to their families,
colleagues
 8. Confidentiality

• There are indeed instances when confidentiality is morally and legally violated, as in a
case of suspected child abuse or a physically incompetent pilot whose uncontrolled
sleep apnea places his passengers at risk.

• Confidentiality can be violated if it incurs risks to other people or to society. Many

ethicists agree that “patient confidentiality is not an absolute rule, and privacy is
not an absolute right.”
 8. Confidentiality

• The Oath states that “whatsoever I see or hear in the course of my profession . . .

I will never divulge, holding such things to be holy secrets.” when should

confidentiality be breached in dental setting?

• Many ethicists believe that confidentiality can be overridden when there is

sufficient evidence to indicate that the patient would be harmed by

maintaining confidentiality.
 8. Confidentiality

• Doctor’s obligation to honor his confidentiality is important

• But Patient problem is so severe that, if he refuses to tell his parents, your obligation is
to inform them. Your intent and effort are designed to protect him from further self-
destructive behavior and provide adequate justification for overriding confidentiality.

• You can then only hope that his parents will offer him unconditional support in his
rehabilitation.

•
Limit of Confidentiality

• Confidentiality of the medical records of HIV-positive patients

• Personal information about them will be shared within the health care team,
including some nonclinical staff involved in their care respecting patient’s Autonomy

• The doctor is aware that a HIV-positive patient has not informed their sexual
partner, it would be permissible for the doctor to alert that partner in order for them
to take steps to avoid infection even if the patient refuses to consent to others being
informed
 9. Gratitude

• It is a way of showing respect for people previously helped you

• Some philosophers believed, its your duty to repay such help even over and

above any good that will come to you or other party

10. Reparation

• If one is responsible for injury to another. There is a duty of reparation to make

amends?
• If any advent reaction occur during reparation, dentist should do compensation
by reparation
Ethical values: are statements of human obligations or duties that are generally
accepted

1. Value: is what we choose freely and thoughtfully as worthwhile or have merit, in a

general or broad sense

2. Value System: the ways in which we organize, rank, prioritize, and make decisions
based on our values

3. Virtues: values turned into actions

Value Value System Virtues

 Value Value System Virtues

I profess that honesty is

one of the important
policy I never lie or deceive I am an honest person
 Where did you get your values?
• Family education
• School education
• The culture in which you live- – (ethnicity, religion, language)
• Peer group
• What society said was right and wrong when you were growing up
 Central Values of Dental Practice
• There are six value categories recognized by the dental profession in its
approaches to treatment

• The important of these values in clinical decision making and propose a

ranking values to help clarify the decision making process when values
conflict
The values, in their hierarchical order, are as follows:
Patient’s life
& General
Health

Patient’s Oral Health

Patient’s Autonomy

Dentist’s preferred practice values

Esthetic values

Efficiency in the use of resources

 1. Patient’s Life and General Health

• The patient’s life and general health are the highest ranking of central values

• Under normal circumstances, dentists should not undertake treatment that with

significantly jeopardize the life or health of patients

• A dentist who paid no attention to the connections between a patients

oral condition and the other aspects of the patient’s health would be guilty of professional

failure
E.g
1. Dental Extraction in patients diagnosed with Hemophilia
2. Orthodontic treatment in uncontrolled diabtes
• May jeopardize their overall health
 2. The Patient’s Oral Health

• Appropriate and pain-free oral functioning is the next most important value

• A dentist who leaves a patient with significant oral impairment or painful

oral functioning would be unethical
 3. Patient’s Autonomy

• Autonomy refers to the ability of patients to make their own health care decisions that
reflect their own values and goals

• When patients refuse further treatment on teeth and request that they be extracted, they
are expressing autonomy. The dentist believes the tooth can be saved and disagrees with
the patient’s choice. In this case, the request is reasonable and can be met

• On the other hand, if the patient request treatment that would be appreciably
compromise oral health, and if the dentist acted on the patients request out of respect for
the patients autonomy and did the procedure, the dentist would be acting unprofessionally
 4. The dentist’s preferred practice patterns:

• A dentist has choices in terms of diagnostic, operative and other dental

procedures or materials that will ensure the best outcome

• In consideration of patient outcomes, patient comfort, efficiency, doctors comfort

and trust in procedure. But the fact that a dentist has a habit of practicing a
certain way does not outweigh a patients autonomous choice, if general and oral
health are not compromised
 5. Esthetic Values

• Shaping a restoration to proper form and function is part of general and oral health as
well as the capacity of the dentist to apply his/her expertise for the patients benefit

• If the patient’s judgment about esthetic values is counter to any of these, esthetic values
would rank below the other values. Acting on patient’s judgments of appearance never
justifies damaging health teeth
 6. Efficiency in the Use of Resources

• Efficiency is something that virtually all dentists perceive as essential for

operation of a successful practice

• There is nothing unprofessional in a dentist’s working to control costs- in

time, effort or materials- provided the other central values are also given their
due
Ethical theories
 1. The virtue theory

• It is focused on evaluating the character of an individual and how he or she acts, as

opposed to concentrating on the act itself

• In other words, one whose acts are virtuous is ethical

• One who is disposed to do right, intends to do right, and does and promotes good
even if it is opposed to that person’s self interest merely

because to do so is the right thing to do may be considered to be acting ethically

• Beneficence and fidelity are paramount under this theory

 2. Kantian Theory (Deontology)

This theory states that people should adhere to their obligations and duties. This means
action should adhere to a Rule or Rules and not on the consequences of the action.

Basis for Kantian Theory

• Always keep promises

• Always follow law

• Make consistent decisions based on his set duties

• Recognize acts of supererogation

 2. Kantian Theory (Deontology)

This theory states that people should adhere to their obligations and duties. This means
action should adhere to a Rule or Rules and not on the consequences of the action.

Basis for Kantian Theory

• Always keep promises

• Always follow law

• Make consistent decisions based on his set duties

• Recognize acts of supererogation

 2. Kantian Theory
Kantian Theory is based on the following principles

1. Do follow the unbreakable moral rule.

2. Not to break a rule even if breaking a rule is likely to improve the outcome.

3. Following rules is the right thing to do.

4. Kantian theory says “means should justify the ends”.

 3. The Utilitarian theory

• It is founded on the ability to predict the consequences of an action. To a utilitarian,

the choice that yields the greatest benefit to the most people is the choice which is
ethically correct.

There are two types of utilitarianism, act utilitarianism and rule utilitarianism.

1. Act utilitarianism - The act which is most beneficial to most regardless of personal
feelings or the societal constraints such as laws or rules.

2. Rule utilitarianism- The act which is most beneficial keeping in mind the
law/rule/fairness. The added benefits of rule utilitarianism are that it values Justice
and includes beneficence at the same time.
The trolley problem!!
Whose life are you willing to sacrifice?

Innocent Person

Prisoners
 What are codes of ethics?

• Many dental organizations have published codes of ethical conduct to guide

member dentists in their practice.

For example; the ADA has had a Code of Ethics since 1866.

• A code of ethics marks the moral boundaries within which professional services
may be ethically provided.

• Codes of ethics and professional guidelines have quasi-legal force; non-compliance

can result in sanctions from censure to loss of professional status.
 Advisory Opinions

The Advisory Opinions are interpretations that apply the Code of Professional

Conduct to specific fact situations and to provide guidance to the membership

on how the Council might interpret the Code of Professional Conduct in a

disciplinary proceeding.
References

1. AJames TR., Robert MV. Ethical Questions in Dentistry. 2nd Edition (2004),
Quintessence publication.

2. M. Brennan, R. Oliver, B. Harvey, G. Jones Ethics and Law for the Dental
Team 1st edition (2006), PasTest
Thank you