of the agreement. Contracts can be expressed orally or in writing or implied by signs, inaction, or silence. In dentistry, the relationship and roles and responsibilities of both parties, the practitioner and patient, can be defined in terms of a contract (Colgate-Palmolive, 2021). Examples of professional contractual responsibilities include: ● Being properly licensed and registered. ● Exercising reasonable skill and judgment in providing care. ● Referring when appropriate. ● Respecting patients’ confidentiality. ● Practicing within the standard of care and providing treatment in a reasonable timeframe. ● Honor the patient’s individual needs and do no harm. Conversely, patient contractual responsibilities include: ● Paying for services rendered in a reasonable amount of time. ● Keeping appointments. ● Providing accurate health history information. ● Cooperating in care. ● Following at-home care instructions. A tort is defined as an interference with another’s right to enjoy his or her person, privacy, or property which causes someone to suffer harm (Level Up RN 2021). Torts can be intentional or unintentional . Intentional torts involve an element of intent to cause harm and include such offenses as: ● Mental distress (purposeful cause of anguish). ● Defamation (damage to a person’s reputation). ● Interference with property (damage to a person’s property). ● Misrepresentation (incorrect or false representation). Intentional tort offenses relative to the practice of dentistry may include: ● Failure to get informed consent (battery). ● Promising a cure or other outcome that is not practically attainable (misrepresentation). ● A patient making a derogatory statement about a dentist (defamation). Unintentional torts include negligence (failure to act appropriately) and malpractice (acting inappropriately). Although an unintentional tort involves no intention to do harm, the following has taken place: ● A recognized legal duty or responsibility owed to the patient was breached. ● The patient was harmed, damaged, or injured. ● The breach of duty was the primary or proximate cause of the harm. Both negligence and malpractice involve practicing below the standard of care. A breach of duty occurs when a dental provider behaves in such a way that his or her actions give rise to a risk of harm to the patient. The provider has the duty to provide treatment that will not cause such harm (ADA, 2020a). This concept is rooted in the ethical principle of nonmaleficence. The legal aspects of any ethical case should be examined but cannot be the sole consideration in the decision-making process. Providers need to know the law in their jurisdictions, strive to obey it, and always consider it. What is ethical is usually also legal, but the converse may not always be true (Prasad, et. al., 2019). Breaches of the law may constitute unethical behavior, but not necessarily in every situation. As the law and ethics intersect in any given case, the decision maker must look for common ground and points of opposition or intersection, then determine a course of action. Consider the following case: ● Assault (threat of bodily harm). ● Battery (unauthorized touching). ● False imprisonment (unlawful restraint).
George has always been a rebellious child. He is now 17 and has been estranged from his parents for more than a year. He and his parents do not see eye to eye on a lot of issues, and he has finally left home after admitting to them that he has a drug problem but is not ready for treatment. For a while, he has lived on the streets. About six months ago, however, he moved in with a 20-year-old friend in a rundown apartment. At least now he has a roof over his head. He is able to support himself with menial jobs. He is not in school, but he has been trying to clean up his act. George has no desire to have any contact with his family, and he has no health or dental insurance. His parents have no idea where he is, and George wants to keep it that way. Because of his drug habit, George has some major problems with his teeth. Multiple deep carious lesions have gone untreated, and now he is experiencing the severe pain and visible swelling of a serious infection. George has called the neighborhood dental office owned by Dr. Cooper and has made an appointment for emergency care. On the phone, George did not disclose that he is a minor and would not have a parent accompanying him to his appointment. He also has no idea how much treatment will cost, but he does not care. He needs to be out of pain. When Dr. Cooper notices George’s age on his health history, he questions George about why his parents have not come with him. George tells Dr. Cooper he does not talk to his parents and his parents do not know where he lives. He is on his own. Dr. Cooper faces a serious dilemma in this case, with legal implications. Should he treat George for the serious infection without parental consent even though that would be technically illegal in his state? Should he refuse to treat George and dismiss him from his practice because of his minor status? If he dismisses him, the infection will probably go untreated and George could suffer serious health consequences, perhaps even death. Thinking back to his ethics training, Dr. Cooper remembers the central values of dental practice that state that the patient’s life and general health are the central concerns for all clinicians and patients and must be considered the number one priority in determining a course of action in any ethical case (Prasad, et al, 2019). He then decides that taking care of this patient’s dire need is a more ethically appropriate choice than following the strict law of the land. Because of the seriousness of the infection, Dr. Cooper chooses to treat George’s infection by surgically draining the abscess and placing him on antibiotics. He also accepts half the fee charged as payment in full, as that is all George can afford. As is evident in this case, ethical and legal standards do not always coincide, and the legal standards can vary from state to state. States define the age of majority, or the age at which a person is legally able to make adult decisions regarding his or her health care. A 17-year-old in George’s position might be able to make independent healthcare decisions legally in some states, whereas in Dr. Cooper’s state, the age that this is permissible is 18. Although every potential legal or ethical situation cannot be anticipated or accounted for in either the ADA Code (2020a) or any given state’s Dental Practice Act, it is important to appreciate how the two documents complement and support each other and to understand their underlying foundation in law and ethics. In different ways, both documents offer sound guidance to the process of managing ethical and legal challenges. It is prudent for every dental practitioner to be intimately familiar with both the ADA Code (2020a) and his or her individual state’s Dental Practice Act for the protection of his or her patients and the ethically and legally sound practice of dentistry.
CURRENT AND EMERGING ETHICAL CHALLENGES TO THE PROFESSION
Dentistry has always had its ethical challenges, but in today’s world these challenges are both more numerous and more
complex. Just as events forced the need for further examination of medical ethics as a whole in the 20th century, the 21st century
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Book Code: DFL3024
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