Solving ethical dilemmas in
dental hygiene practice
www.rdhmag.com • December 03, 2020
By Marcy Ortiz, RDH, BA
Ethics is a difficult concept to define because it is viewed very
differently depending on the particular dilemma. Doing the right
thing when confronted with a difficult circumstance is one way
to define ethical behavior. Ethical is also defined as “maximizing
the good while minimizing the bad,”1 or according to Merriam
Webster, ethics is “the discipline dealing with what is good and
bad and with moral duty and obligation.”2 Another definition is
being professional and being able to deal with morally
perplexing situations.3 Regardless of the definition, it is not
always easy to do the right thing in a given circumstance
because the right choice may not always benefit the hygienist’s
best interests.
Dental professionals, including dental hygienists, are confronted
daily with difficult choices that require decisive action and
judgment calls for which careful deliberation is required.4 To
enable a fair consideration for all parties, certain guidelines or
health-care principles are available to “weigh the potential
consequences (benefits and harm) and the rights and general
welfare of all involved.”4 The four principles of health-care
ethics are autonomy, beneficence, nonmaleficence, and justice5
(see chart 1). “Beneficence and nonmaleficence are often linked
because both are found in the Hippocratic tradition, which
requires the physician [dentist or hygienist] to do what will best
benefit the patient.”1 It is important for the dental hygienist to
consider all four ethical principles when weighing a moral
dilemma regarding patients.
An ethical dilemma occurs when one of the above principles
conflicts with another.1 For example, a patient decides he or she
wants to save money by refusing X-rays for the fourth year in a
row. The patient is exercising his or her autonomy. However, the
hygienist realizes this puts him or her in an ethical dilemma. Not
taking X-rays for so long is a form of nonmaleficence, and it does
not benefit the patient and can harm the patient due to
undetected periodontal disease, decay, pathology, and more.
Practicing in the dental profession, dental hygienists see an
array of ethical concerns while treating patients. These
dilemmas can vary depending on the type of practice, specialty,
and age of patients in the practice. However, there are some
ethical areas that are more common and will be highlighted
here. The specific case examples that follow relate to the ethical
principles presented in chart 1, and values that correspond to
these principles in our profession.
Paternalism vs. informed consent
Paternalism is the practice of acting as the “parent,” which is
taking it upon oneself to make decisions for the patient. Years
ago the “doctor knows best” approach regarding treatment was
common. The doctor merely picked a course of treatment he or
she thought was best for the patient. Of course, paternalism is
not acceptable today because it eliminates patients’ right to
choose the treatment they feel is right for them, even if their
choice is not what the doctor feels is best.
Here is an example of paternalism. The patient is given a
treatment plan of extracting a painful tooth and fabricating a
three-unit bridge for tooth replacement. Due to the patient’s
age, the dentist feels this is the easiest approach so the tooth
will not give the patient any problems in the future. In this case,
there is no mention of possible endodontic treatment or
replacing the extracted tooth (if extraction is required) with an
implant. Paternalism violates this patient’s autonomy and self-
determination, and ethically involves nonmaleficence due to not
giving the patient the right to informed consent; thus,
paternalism is the opposite of informed consent. This patient did
not have all the information needed to make an informed
decision for care.
Informed consent is highly recommended for today’s progressive
medical and dental treatment. This allows for patient autonomy,
self-determination, and beneficence, thus avoiding paternalism.
Dental offices, like medical offices, are able to “provide patients
a financial estimate for prostheses and other treatments,” and
even have patients sign a document acknowledging their
financial agreement.6 This agreement helps patients understand
their alternatives regarding treatment. The agreement may even
state estimates relating to each treatment option.
Informed consent requires opening the lines of communication
between provider (dentist or hygienist) and patients. The
provider needs to make sure patients understand their options,
and patients then acknowledge they have all the information,
benefits, and risks along with their financial obligation.
Interestingly, many providers do not take into account the pain
people will experience as an ethical problem — “for some, pain
still seems to be only a technical problem solved by treatment.”6
Pain is an ethical concern for patients and should be
incorporated into the informed consent information when
presenting options for patients. Pain can have a substantial
effect on the treatment options patients consider.
Supervised neglect
In today’s economic climate, one would assume overselling or
overtreatment would be more widespread than supervised
neglect, but surprisingly, supervised neglect does occur, even in
good dental practices. There are conditions when patients slip
through the cracks, or long-term patients become so
comfortable in a practice they’re allowed a great amount of
autonomy, which becomes a detriment to their best interest.
Beneficence now becomes a concern. To illustrate supervised
neglect, two case examples show common dental care dilemmas
hygienists experience — periodontal disease treated
conservatively in high-risk patients, and radiographic refusal.
Both these situations result in cause for disagreement between
the dental hygienist and his or her employer in which an ethical
dilemma will ensue.
1) A long-term periodontal patient is currently receiving
periodontal maintenance recalls every three months. He is a
diabetic patient with normal A1C scores. After receiving root
planing, periodontal pocketing is still out of control, with depths
ranging from 4 mm to 9mm. The hygienist is beyond frustrated
because she feels she is in over her head. The dentist does not
think the patient will consider a periodontal referral due to his
age and advanced periodontal condition; thus no referral is
offered (paternalism, nonmaleficence). In this example,
nonmaleficence is the primary ethical principle at issue.
Nonmaleficence is included in the ADA Code of Professional
Conduct description as doing no harm and “… knowing one’s
limitations and when to refer to a specialist or another
professional.”7
What is the hygienist to do? She discusses the patient’s options
during a few maintenance appointments and stresses he will
eventually lose some teeth if further treatment is not
considered. She gently explains she has done everything she can
in her scope of practice, and yet the periodontal disease is still
active. Not surprisingly, this patient did not want to lose his
teeth and agreed to see the periodontist for further treatment
(informed consent in action). Unfortunately, the patient did lose
several teeth that had advanced periodontal pocketing, but he is
now receiving active periodontal therapy via the periodontist
(beneficence).
2) Radiographic refusal is a huge problem in many practices due
to the economy and lack of insurance. This case involves a
patient who has refused any type of X-ray since 2005. Yes, that is
seven years without an X-ray! The patient merely signed a
release and spent the money he saved on his next vacation.
During one prophylaxis recall, he stated he could not receive X-
rays because he just paid for his rental car to the Bahamas, and
besides, he did not have insurance! The dentist did not push the
patient to consider X-rays and had no intention of dismissing
him from the practice. The patient was practicing his autonomy;
however, the dentist was not considering beneficence for this
patient.
This patient developed a moderate amount of calculus and a
suspicious area on the lingual of tooth No. 31 (part of a three-
unit bridge). The treating hygienist explained, once again, the
need for X-rays. She stressed that she was working blind
regarding subgingival calculus detection and removal without
the aid of any current X-rays, and “who really knows what is
occurring under No. 31?” Reluctantly, the patient agreed to an
FMX the next visit. Luckily, his calculus formation is now under
control, with no subgingival evidence on the X-rays. However,
tooth No. 31 is not so lucky.
The tooth is completely decayed from the gingival margin, under
the crown, and it continues deep into the apices. Surprisingly,
the patient has no pain. He asked about his treatment options
for this decayed tooth, which will cost thousands to replace with
an implant, as it requires extraction. If the decay had been
detected earlier via routine X-rays, a new three-unit bridge
could have been fabricated because this tooth had enough bone
to warrant a new bridge.
The patient feels awful, and the dentist feels terrible for the
patient, but he does not see that this as a case of supervised
neglect. Instead, the dentist puts the blame on the patient for
refusing the care offered. It is true that the ADA ethical code’s
first principle is “patient autonomy” [it states in part],
“professionals have a duty to treat the patient according to the
patient’s desires, within the bounds of accepted treatment.”8
Seven years without X-rays is not within the bounds of accepted
treatment. Nonetheless, patients do have an involvement in their
care, and if the provider feels a patient’s refusal of X-rays is
limiting diagnostic capabilities, a dentist “may consider
discussing with the patient options regarding consultation with
or treatment by another dentist.”8
Model for working through ethical
dilemmas
These ethical dilemmas, though typical, are still difficult to work
through in each situation. Patients deserve to exercise their self-
determination, but not at the risk of their dental health. Dental
professionals must weigh options that allow a patient’s
autonomy while exercising beneficence and avoiding
maleficence. Exercises or decision models can help work
through each dilemma to reach an ethical decision. An effective
model for dental health-care professionals to evaluate and solve
ethical dilemmas is illustrated in “Ethics and Law in Dental
Hygiene” (2010) by Phyllis L. Beemsterboer. Beemsterboer
outlines the following six-step decision-making model.1
1. Identify the ethical dilemma or problem
2. Collect information
3. State the options
4. Apply the ethical principle to the options
5. Make the decision
6. Implement the decision
The first step, identify the ethical dilemma, is to pinpoint the
ethical problem. Do you have a legitimate ethical dilemma? Are
principles in conflict? State the specific conflict, then evaluate
and apply the specific health-care principles that conflict with
one another. Without a conflict of principles, there is no ethical
problem but merely a right or wrong type of predicament.
Step two, collect specific information, is critical to the case in
question. The information can be specific statements of fact and
can come from a variety of sources pertaining to how the
conflict began, how it proceeded, and what parties are involved.
Information collection is necessary to make a balanced ethical
decision.
Step three, state the options, is a step-by-step process or
analysis to judge each option and the consequences related to
each option. Troubleshoot as many options and their full
consequences before proceeding to the next step.
In step four, apply the ethical principles to the options.
Beemsterboer recommends, “State how each alternative will
affect the ethical principle or rule by developing a list of pros
and cons.”1 List each principle violated while considering
specific values such as supervised neglect, informed consent,
paternalism, and more. Show the pros and cons of each option
and its consequences discussed in step three.
Step five, make the decision, is now apparent by evaluating your
pro and con worksheet. One would assume the option with the
most pros would be the correct decision, but carefully
evaluating the degree of severity regarding the consequences in
the con column may have an affect on your decision.
In step six, you are now ready to implement the decision. There
is no sense in going through these six steps unless you’re
serious about implementing the decision to your ethical
dilemma. Without following through and acting on your decision
to the ethical dilemma, there will be no resolution for the patient
or party affected.
Conclusion
Knowing the major principles of health-care ethics and how to
use a model to solve an ethical conflict is the best way to solve a
dilemma. Weighing all outcomes is necessary to reach a fair
resolution for each party. Working through an ethical dilemma
does not come easily, but takes practice and careful
consideration. This is why educational ethics programs in dental
hygiene schools are important. When instituted within the
curriculum, hygienists have the opportunity to participate in
group instruction and use workshops to role-play. Through this,
dental hygiene students see “how experienced ethicists reason
through problems,” and there are “right answers to ethical
problems and that it is not just a ‘matter of opinion.’”9
To date, there appears to be no gold standard in teaching ethics
to dental hygiene students. However, allowing students a
personal experience via instruction and role-playing engages
students in realistic ethical discernment, which gives them the
“tools necessary to deconstruct an ethical dilemma.”4
Continuing and broadening school-setting ethical training
instruction is necessary to increase hygienists’ awareness in
solving ethical conflicts. Then hygienists can address, analyze,
and solve ethical dilemmas properly using their ethical training
within the “context of clinical, workplace, and professional
situation[s].”4 RDH
Marcy Ortiz, RDH, BA, is a practicing dental hygienist for
25 years, the last 16 years in a geriatric dental practice in
Sun City West, Ariz. She is a 2010 Arizona State University
alumna graduating summa cum laude and a member of
the Golden Key International Honour Society. She is the
current vice president of education for Camelback
Toastmasters in Glendale, Ariz. and recently awarded
2010-11 Outstanding Area Y7 Toastmaster of the year.
Marcy can be contacted at Ortiz7688@cox.net.
References
1. Beemsterboer P. (2010). Ethics and law in dental hygiene (2nd
Ed.). St Louis, MO: Saunders Elsevier.
2. Ethics Definition. Retrieved Dec. 27, 2011 from http://
www.merriam-webster.com/dictionary/ethic
3. Shaw DD. (2009) Ethics, professionalism and fitness to
practice: three concepts, not one. British Dental Journal. 207(2),
59-62.
4. Brondani MA, Rossoff LP. (Nov. 2010). The “hot seat”
experience: a multifaceted approach to the teaching of ethics in
a dental curriculum. J Am Dent Educ., 74(11):1120-1229.
5. Brennan M. (March 2010). Why bother with ethics and law?
Vital [serial online] 7(2): 37-39. Retrieved from: Academic
Search Complete, Ipswich, Ma Accessed December 28, 2011.
6. Hamel O et al. (2006). Ethical reflection in dentistry: first
steps at the faculty of dental surgery of Toulouse. J Am Coll
Dent., 73(3): 36-39.
7. Wentworth R. (Sept. 2010). Ethical moment: what ethical
issues should general dentists consider when the state of the
economy affects decisions regarding referral of patients to
specialists. J Am Dental Assoc., 141 (9) p. 1125-1126. Retreived
online Dec. 9, 2011 from http://jada.ada.org/content/
141/9/1125.full
8. Wentworth R. (June 2010). Ethical moment: what ethical
responsibilities do I have with regard to radiographs for my
patient? J Am Dental Assoc. 141 (10): 718-720. Retreived Dec. 9,
2011 from http://jada.info/content/141/6/718.full?related-
urls=yes&legid=jada;141/6/718
9. Jenson L. (February 2005). Why our ethics curricula do work.
J Dent Educ., 69(2):225-8.
Chart 1
Four principles of health-care ethics1,4,5
Autonomy
• Includes “Self-determination, the right to decide what
happens or does not happen to us”5
• Knowledge of all information regarding treatment, risk, and
benefits
• Patients make their own decisions, the right to say yes or no
to treatment
• Patients have a right to confidentiality and privacy regarding
their health care
Beneficence
• Promote good for the patient; protect the patient from harm
• Acting in the best interest of the patient
Nonmaleficence
• Do no harm
• Do not undertake a procedure without the patient’s consent
(informed consent) or do a procedure for which you are not
adequately trained
Justice
• Be fair and treat patients equally
• Do not discriminate any patient seeking a dental diagnosis or
treatment
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