Ethics in Dentistry: Guiding Principles for Patient Care and Professional Integrity

ETHICS IN DENTISTRY
Presented by- Dr. Poonam Narang
Batch- 2023-26
Department Of Public Health Dentistry
Government Dental College, Raipur

CONTENT
 INTRODUCTION
 DEFINITION OF ETHICS
 DENTAL ETHICS
 HISTORY OF ETHICS
 ETHICAL PRINCIPLES
 UNETHICAL PRACTICES
 SOME UNETHICAL STUDIES IN HISTORY
 UNETHICAL EXPERIMENTS IN TODAY'S MEDICINE
 The IDA Code of Ethics
 CONCLUSION
 REFERENCE

INTRODUCTION
 The dental profession is a vocation in which knowledge
and skill is used for the service of others.
One of the characteristics of a profession is adherence to a
code of ethics. As healthcare providers, dental
professionals carry a responsibility not only to individual
patients but also to society as a whole.

‘ETHICS’
‘ETHOS’ (Greek)
Custom /
Character
It is the philosophy
of human conduct, a
way of stating &
evaluating principles
by which problems of
behaviour can be
solved.

 Ethics is concerned with standard judging
whether actions are right or wrong.

What is Ethics?
 It’s a branch of philosophy concerned with the study of
those concepts that are used to evaluate human
activities, in particular the concepts of goodness and
obligation.
Dental ethics would mean moral duties and obligations
of the dentist towards his patients, professional
colleagues and to the society

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

DENTAL ETHICS
 Dental ethics simply means moral duties and
obligations of the dentists towards the
patients ,professional colleagues and to the society.
 These help support autonomy and self
determination , protect the vulnerable and promote
the welfare and equality of human beings.
 It deals with choices made by both clinicians and
patients

Ethical
principal
Micro
ethical
principal
Macro
ethical
principal

Micro-ethical principles
They focus primarily on individuals’ rights and
duties and do not see individuals as part of a
wider social order.

Macro-ethical principles
These are a set of principles designed to
protect the human dignity, integrity, self
determination, confidentiality, rights and health
of populations and the people comprising
them.

History of Ethics
Ancient Greek ethics
Hippocratic oath is the first ethical standards given by
Hippocrates, the father of medicine, in the 4th century BC
It is perhaps the most widely known of Greek medical texts.

 Over the centuries, it has been rewritten often in order
to suit the values of different cultures influenced by
Greek medicine.
 Contrary to popular belief, the Hippocratic Oath is not
required by most modern medical schools, although
some have adopted modern versions that suit many in
the profession in the 21st
century

Ancient Greek ethics
Socrates (5th century BC) –
 Some problems are resolvable by data (e.g., geometry),
while others are moral issues (e.g., justice system)
 Socrates, as portrayed in Plato's Republic, articulates the
greatest good as the transcendent "form of good itself".

Plato (5th-4th century BC)
 Like most other ancient philosophers, Plato maintains
a virtue-based, eudaemonistic view of ethics.
 He believed happiness or well-being (eudaimonia) is
the ultimate goal of moral thought and action.

Aristotle (4th century BC)
 Aristotle's ethics builds upon Plato's with important variations.
Aristotle's highest good was not the good itself but goodness
embodied in a flourishing human life.
 Following Plato, Aristotle gives a significant role in moral life
the virtues, fixed habits of behavior that lead to good outcomes.
 He viewed intellectual activity as the highest form of life.

Kantian ethics
 Immanuel Kant, in the 18th century, argued that
right and wrong are founded on duty, which issues
a Categorical Imperative to us, a command that,
of its nature, ought to be obeyed.
 To decide what duty requires, Kant proposes the
principle of universalisability correct moral rules are
those everyone could adopt.

Natural law ethics
In the Middle Ages , Thomas Aquinas developed
a synthesis of Biblical and Aristotelian ethics
called natural law theory.
This theory states that human nature determines
what is right and wrong.
Education is needed for humans, and is their right,
because it necessary for developing the
intellectual nature of humans.

Utilitarianism
 In 19th century Britain, Jeremy Bentham and John Stuart
Mill advocated utilitarianism.
 Utilitarianism: actions are right if they maximize happiness for
the most people.
 Supports liberal political ideas and Enlightenment individualism,
like Kantianism.

 In India, the Dentist Act of 1948 was amended via
section 17A empowering the Dental Council of India to
prescribe standards of professional conduct & etiquette.
 The Code of Ethics was framed by the Dental Council in
1975 & later notified by the Government of India as “
Dentists (code of ethics) Regulations 1976.
It is in force from August 1976.

ETHICAL PRINCIPLES
 To do no harm [ non-maleficence ]
 To do good [ beneficence ]
 Respect the person
 Justice
 Veracity or truthfulness
 Confidentiality

To do no harm [ non-maleficence ]
 Considered to be the foundation of social morality.
 Actions of the healthcare provider should not harm the
patients in anyway

 Iatrogenic diseases-doctor induced illness.
• Use of unsterilized instruments
• Iatrogenic diseases (underfilling, overfilling etc)
• Doing procedures beyond his competency
 The dentist, in cases where pain cannot be avoided, can make
attempts to minimize the pain. If feasible, the alternative of
minimal or no treatment can be presented to the patient.

To do good [ beneficence ]
 Dentists must benefit patients and avoid harm.
 Patients expect care to result in positive outcomes.
 Treatment vs. no treatment consequences must be weighed.
 E.g. in questionable dental caries - the attempts should be
to maximize the benefits and minimize the harm.

Respect the person
It incorporates at least 2 fundamental
ethical considerations :
• Autonomy
• Informed Consent

a) Autonomy
 The health care professionals respect the patient’s right
to make decisions concerning the treatment plan.
 Patients should not be bystanders in their treatment , but
active participants.

 Dentists are often trained in a paternalistic setting, where the
“father knows best” approach dominates.
 Paternalism in healthcare may involve withholding information,
limiting choices, or making decisions for patients.
 Paternalistic laws can be justified in the public’s interest but limit
individual rights for perceived “best interest.”

b)Informed Consent
 Informed Consent is the first stated and the largest principle of the
Nuremberg Code.
 The Nuremberg Code identifies 4 attributes of consent without which
consent cannot be considered valid.
 Consent must be :
 voluntary
 Legally competent
 Informed
 comprehending

Informed consent is a 2 step process.
i. Information is presented to the patient by the doctor i.e.
Patient information sheet.
ii. Patient satisfies himself/herself that he/she understands &
based upon this understanding either agrees or refuses to
undergo treatment

Informed Consent consists of :
• A description of procedures to be carried out.
• An explanation of any foreseeable risks or discomforts.
• A description of potential benefits to the patient or
others.
• Disclosure of alternative procedures or treatments that
may be beneficial to the patient.

 A statement explaining the extent of confidentiality
regarding the patient’s records.
 A statement confirming the patient has understood the
procedure and agrees to the treatment.
 The signatures of the patient and a witness.

Justice
 It is often described as fairness / equal
treatment, giving to each her or his right or due .
 Primary duty of the health professional is service
irrespective of class, creed etc
 Justice requires protecting the vulnerable and
ensuring equity for individuals and groups.

Veracity or truthfulness
 The patient – doctor relationship is based on
trust.
 Lying shows disrespect to the patient and
threatens relationship.
 It is a principle that one would expect to go
unquestioned, yet many health care
professionals practice in a less than truthful way.

Confidentiality
 Patient have the right to expect that all
communications and records pertaining to their
care will be treated as confidential.
 It is very natural to want to gossip about a patient,
particularly if it is someone famous or possibly a
neighbour ,but to do so that would break a bond
of trust between the dental professional and the
patient.

WHY CODE OF MEDICAL AND DENTAL ETHICS?
 Professions have ethical standards as part of their role.
 Patients trust professionals to follow established norms.
 Ethical standards are expected and enforced as part of
self-regulation.

 A systematic body of rules is needed “in order that dignity and
honour of the dental profession may be upheld, its standard
exalted, its sphere of usefulness extended and the advancement
of dental sciences promoted and that the members of the
dental association may understand clearly their duties and
obligations to the dental profession, to their patients, and to the
community at large”
(Indian Dental Association-Constitution, bylaws and code of ethics, 1988).

EHICAL RULES FOR DENTISTS
[given by DCI]
 Duties of dentist towards patients
 Duties of dentists towards one
another
 Duties of dentists towards the public

DUTIES OF DENTIST TOWARDS PATIENTS
 Dentists should be courteous, punctual, and
professional.
 Avoid biases based on religion, race, or politics.
 Keep patient information confidential, including
for staff.

Duties of dentists towards one another
 Dentists should respect and not disparage their
colleagues.
 In emergencies, a dentist should treat the patient and
then defer to the regular dentist, but may charge for their
services.
 Arrange remuneration when covering for another dentist.
 Correct faulty treatment discreetly, avoiding criticism of
the previous dentist.

Duties of dentists towards the public
 Dentist should take leadership roles in the communities
on matters related to dental health.

 Unregistered Practice
 Misleading Certificates
 Inappropriate Advertising
 Bogus Credentials
 Commissions
 Undercutting Charges
 Lack of Referral
 Temporary Care Issues

Some unethical studies in history

1)The Tuskegee Study
 The Tuskegee Study of Untreated Syphilis in the
Negro Male was an infamous and unethical clinical
study conducted between 1932 and 1972 by
the U.S. Public Health Service.
 It observed untreated syphilis in African-American
men who were misled about receiving free
healthcare.
 The study was conducted with Tuskegee University in
Alabama.

ETHICAL PRINCIPLES NOT MET:
 Respect for Human Dignity
 Informed Consent
 Respect for vulnerable persons
 Minimizing harm and maximizing benefit
 Independence of research and conflicts of interest or
partiality must be explicit.

2)The Monster Study (1939)
 The Monster Study (1939) involved 22 orphan
children in Davenport, Iowa, led by Wendell
Johnson and Mary Tudor.
 Children were divided into groups: one received
positive feedback on their speech, while the
other was criticised and labeled as stutterers.

 The Monster Study caused long-term harm to normally speaking
children.
 It was hidden to protect Johnson’s reputation, especially after
WWII.
 The University of Iowa apologized in 2001.

3) THE INHUMAN NAZI EXPERIMENTS
 Nazi human experimentation involved
cruel medical tests on prisoners, including
children, in concentration camps during
WWII.
 Targets included Romani, Sinti, Poles, Soviet
POWs, disabled Germans, and Jews.

 Nazi physicians forced prisoners to participate in
experiments without consent.
 The experiments typically led to death, trauma,
disfigurement, or permanent disability, and are considered
medical torture.

ETHICAL PRINCIPLES NOT MET:
 Respect for Human dignity
 Informed Consent
 Privacy
 Respect for Vulnerable persons
 Minimizing harm and maximizing benefit

Experiments
 Malaria experiments
 Immunization experiments
 Epidemic jaundice
 Mustard gas experiments
 Sulfonamide experiments
 Experiments on twins
 Bone, muscle, and nerve transplantation experiments
 Experiments with poison
 High altitude experiments
 Blood coagulation experiments

Malaria experiments
 At Dachau (1942-1945), malaria experiments involved infecting
inmates and testing treatments in order to investigate
immunisation for treatment of malaria.
 Over 1,200 subjects were used; more than half died, and others
suffered permanent disabilities.

Epidemic jaundice
 From June 1943 till January 1945 at the concentration
camps, Sachsenhausen and Natzweiler, experimentation
with epidemic jaundice was conducted.
 The test subjects were injected with the disease in order
to discover new inoculations for the condition.
 These tests were conducted for the benefit of the
German Armed Forces. Many suffered great pain in
these experiments

Mustard gas experiments
 At various times between September 1939 and April 1945, many
experiments were conducted at Sachsenhausen, Natzweiler, and other
camps to investigate the most effective treatment of wounds caused
by mustard gas.
 Subjects were exposed to mustard gas and other chemicals, causing
severe burns, to find effective treatments.

Sulfonamide experiments
 From July 1942 to September 1943, Ravensbrück tested sulfonamide
on infected wounds.
 Subjects’ wounds were deliberately infected with bacteria and aggravated
with wood shavings and glass.
 The infections were then treated with sulfonamide and other drugs to assess
effectiveness.

Blood coagulation experiments
 Sigmund Rascher tested Polygal, a blood-clotting
substance, on prisoners.
 Subjects were given Polygal and then shot or had limbs
amputated without anesthesia.
 Rascher published an article on Polygal and established a
company to manufacture it, using prisoners as staff.

THE NUREMBERG CODE
 It is a set of research ethical principles for human
experimentation set as a result of the Nuremberg
trials at the end of 2nd
World War.
 It emphasizes ethical research, requiring voluntary
consent from subjects.

➢ Voluntary informed consent is essential and cannot be
delegated.
➢ Experiments must provide valuable results for society and not
be random or unnecessary.
➢ Experiments should be based on prior animal studies and
knowledge of the disease, with justified anticipated results.
➢ Experiments must avoid unnecessary physical and mental
suffering.
➢ No experiment should be conducted if there is a prior belief
that it will cause death or disabling injury.

The risk should not exceed the humanitarian importance of the
experiment.
Adequate preparations and facilities must be provided to protect
subjects from injury, disability, or death.
Only scientifically qualified persons should conduct experiments with
the highest skill and care.
Subjects must be free to end the experiment if they reach a point
where continuation is intolerable.
The scientist must be ready to terminate the experiment if continuation
risks injury, disability, or death.

DECLARATION OF GENEVA
 Was taken in the 2nd
General Assembly of World
Medical Association , Geneva 1948.
 This oath seems to be a response to the atrocities
committed by doctors in Nazi Germany.
 Notably this oath requires the physician to “not use
(his) medical knowledge contrary to the laws of
humanity”
 It is also called as Physician’s Pledge.

At the time of being admitted as a member of the medical profession:
The pledge reads :
➢ I SOLEMNLY PLEDGE to dedicate my life to the service of humanity.
➢ THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration.
➢ I WILL PRACTICE my profession with conscience and dignity.
➢ I WILL RESPECT the secrets that are confined in me, even after the
patient has died.

➢ I WILL MAINTAIN by all means in my power , the honour and the noble
traditions of the medical profession.
➢ MY COLLEAGUES will be my sisters and brothers.
➢ THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration
➢ I WILL MAINTAIN the utmost respect for human life.
➢ I WILL NOT USE my medical knowledge to violate human rights and civil
liberties, even under threat;
➢ I MAKE THESE PROMISES solemnly, freely and upon my honour.

WORLD MEDICAL ASSOCIATION INTERNATIONAL CODE OF
MEDICAL ETHICS
 Adopted in the 3rd
General Assembly of World Medical
Association , London October 1949
 It states the duties of physician in general, to patients
and to colleagues.

DECLARATION OF HELSINSKI – 1964
 The Declaration of Helsinki sets ethical guidelines for human research.
 It is a key document on research ethics.
 The Declaration of Geneva prioritizes patient health, and the
International Code of Medical Ethics emphasizes acting in the
patient’s best interest.
 Research must be based on solid scientific knowledge.

 Research must be conducted by trained investigators using approved
protocols.
 The rights and interests of subjects must take precedence over
generating new knowledge.
 Study information should be publicly available.
 Research should minimize harm to the environment.
 Placebo or no treatment groups may be used under certain conditions.

Unethical experiments in today's medicine
 Updated January 22, 2019
 Chinese scientist He Jiankui sent shockwaves
around the world last year with his claim that
he had modified twin babies' DNA before
their birth and made the babies resistant to
HIV.
 Scientists from China and around the world
spoke out about the experiment, which many
say was unethical and not needed to prevent
the virus. The scientist had also been warned
by peers not to go down this path.

Bombshell: Secret American Laboratory Performs Deadly Human
Experiments in Caucasus’ Georgia
 At a recent international meeting in Geneva, representatives of
Georgia’s breakaway region of South Ossetia expressed concern that
the “Lugar Laboratory” in Tbilisi was contributing to increased
outbreaks of dangerous diseases in South Ossetia.

 However, Russia’s former Chief Sanitary Inspector, Gennady
Onishchenko, suggested last year that the United States may be
spreading Zika-infected mosquitos in Georgia’s breakaway
Abkhazia region as a form of biological warfare against Russia
 He told the BBC Russian Service that the discovery of Zika-infected
mosquitoes in Abkhazia’s Black Sea coast “worried” him “because
about 100 kilometers from the place where this mosquito now lives,
right near our borders, there is a military, microbiological laboratory
of the Army of the United States.”

RECENT UN ETHICAL TRIALS IN INDIA
 The question whether all human clinical trials undertaken in India are
conducted ethically has been answered. The final report of the three-
member committee appointed by the central government to go into the
alleged irregularities in the conduct of the human papilloma virus (HPV)
vaccine trial reveals gross ethical violations.
 The trial, suspended since March 2010, was carried out by the Program for
Appropriate Technology and Health(PATH), an NGO, in collaboration with
the Andhra Pradesh and Gujarat governments and the Indian Council of
Medical Research.
 It was conducted on nearly 23,500 girls in the 10-14 years age group in
Khammam district (Andhra Pradesh) and Vadodra (Gujarat). The “casual
approach,” which saw the informed consent forms, the most sacrosanct
trial documents, being filled “very carelessly” with “incomplete and
probably inaccurate” information is shocking.

 In Andhra Pradesh, nearly 2,800 consent forms were signed by a
hostel warden or headmaster, as the ‘guardian'. Since students
have “reduced autonomy,” the fact that teachers played a
“primary role” in explaining and “obtaining consent” meant that
the consent was obtained under duress, in a legally untenable way
 The trial came under scrutiny following a public outcry over the
death of seven children. Although the cause of the deaths was
found to be unrelated to vaccination, the incident revealed a total
failure of the mechanism to monitor the ‘volunteers' for both serious
and non-serious adverse events following vaccination. There was a
five-month delay in reporting a death, while two deaths in
Khammam district went unreported.

Issues faced by participants in a COVID-19 vaccine trial in
Bhopal, India, including lack of informed consent and
difficulties reporting adverse events. Many participants were
illiterate and did not understand they were part of a trial.
Elsevier has created a COVID-19 resource centre providing free
access to related research for unrestricted use.

Fernald State School Study (Radiation in Dentistry)
In the 1940s and 1950s, at the Fernald State School in
Massachusetts, researchers exposed mentally disabled children to
radiation in order to study the effects of radiation on teeth and
bones. The children were not informed, and neither they nor their
guardians gave proper consent. This study, conducted by the U.S.
government and MIT, aimed to examine how calcium and
radioactive isotopes were absorbed by the body, but it had dental
implications due to the focus on bone structure and tooth
development.

. The St. Louis Dental Caries Study (1940s)
This study was conducted to understand the causes of dental
caries and involved schoolchildren in St. Louis. Researchers
exposed children to frequent X-rays without their or their parents’
informed consent. The long-term effects of this radiation exposure
were not fully understood at the time, and the study subjected
children to unnecessary risks of radiation-related health issues.

Nutritional Fluoride Study (1940s)
A study conducted in the 1940s aimed to investigate the benefits of
fluoride in preventing dental cavities. While fluoride has been shown
to be effective in cavity prevention, the study involved giving
participants, including children, high doses of fluoride without fully
informing them or their families about the risks. Some participants
suffered from dental fluorosis, a condition caused by excessive
fluoride exposure, which can damage tooth enamel.

The IDA Code of Ethics
 The IDA Code of Ethics is a comprehensive directive on the ethical
codes of conduct an IDA dentist member is expected to follow.
 The IDA code of ethics has been formulated keeping in mind the
DCI Code of Ethics i.e. Dentist’s Act amended in 2016 and
adopted from various international Dental Associations promoting
high standards of patient care matching global standards.
 IDA strives to put India on the global map by holding its members
to a very high standard through the adoption of this Code of
Ethics
 These regulations may be called the Revised IDA Code of Ethics ,
2014.

Codes of ethics
1.Declaration:
Every dentist who has been registered (either on Part A or Part B of the
State Dentists Register) shall, within a period of thirty days from the
date of commencement of these regulations, and every dentist who
gets himself registered after the commencement of these regulations
shall, within a period of thirty days from such registration, make, before
the Registrar of the State Dental Council, a declaration in the form set
out for the purpose in the Schedule to these regulations and shall
agree to have read, understood and thence to abide by the same.

2. Duties and Obligation of Dentists in General
4.1 Character of Dentist / Dental Surgeon
 In view of the important role of a Dentist/ Dental Surgeon as a health
professional educated and trained in surgical and medical treatment of
diseases of the Oral cavity, he shall:
 (4.1.1) Mission Awareness: Acknowledge the importance of their role
and maintain skill and reputation.
 (4.1.2) Patient Priority: Put patient welfare first.
 (4.1.3) Professionalism: Be courteous, sympathetic, and maintain dignity
in all interactions.

4.2 Maintaining good Clinical Practices:
 The Principal objective of the Dental profession is to render
service to humanity with full respect for the dignity of profession
and man. Dental Surgeons should merit the confidence of
patients entrusted to their care, rendering to each a full
measure of service and devotion
 (4.2.1)Scientific Methods: Use evidence-based methods and
avoid those who don’t.
 (4.2.2)Professional Engagement: Join and contribute to dental
and medical associations

4.3 Maintenance of Dental/Medical records:
 (4.3.1) Record Keeping: Maintain patient records for at least three
years in an approved format.
 (4.3.2) IRecord Requests: Provide records to patients or legal
authorities within 72 hours upon receipt.
 (4.3.3) Medical Certificates: Keep a register of all medical
certificates issued.

4.4 Display of Registration Numbers:
 Display the registration number from the State Dental Council
in the clinic and on all prescriptions, certificates, and receipts.
4.5 Prescription of Drugs:
 Prescribe and administer drugs responsibly, favoring generic
forms when possible.
4.6 Highest Quality Assurance in patient care:
 Ensure high-quality treatment and be aware of unethical
practices and unqualified practitioners.

4.7 Exposure of Unethical Conduct:
 Report incompetence, dishonesty, and unethical behaviour
without fear.
 Notify authorities about quackery, abuse, misconduct, and
other social issues.
4.8 Payment of Professional Services:
 Avoid conflicts between financial interests and patient care.
 Announce fees before providing services, not after.

4.9 Observation of Statutes:
 Follow national laws regulating dental practice, including the Dentists’ Act
1948 and amendments.
 Comply with sanitary laws and public health regulations.
 Adhere to state and federal acts related to drugs, cosmetics, narcotics,
environmental protection, and public health.

4.10 Signing Professional Certificates, Reports and other
Documents:
 Registered dental surgeons must sign certificates and reports
related to dental treatment, disability, injury, and deaths.
 Signing false or misleading documents can lead to removal
from the Register.

CONCLUSION
 A profession comprises individuals with specialised skills who
perform societal functions better than the average person.
 Professionals are expected to demonstrate respect for people,
competence, integrity, and a primary focus on service rather than
prestige or profit.
 Ethical codes guide professionals’ moral behavior, addressing
specific challenges within their field. These codes are crucial for
setting high conduct standards, rooted in the right attitudes and
procedures.

REFERENCE
 Peter S. Essentials of Public Health Dentistry. 5th ed. New Delhi: Jaypee
Brothers Medical Publishers; 2021.
 Alva SS, Bhandary S, Damda A. Ethics in dentistry. Int J Curr Res. 2017
Jan;9(01):45692-45695.
 Bagatur E. Nazi Medicine-Part 1: Musculoskeletal Experimentation on
Concentration Camp Prisoners During World War II. Clin Orthop Relat
Res. 2018 Oct;476(10):1899-1905.
 Bhuyan A. India begins COVID-19 vaccination amid trial allegations.
Lancet. 2021 Jan 23;397(10271):264.

 Kurihara C, Kerpel-Fronius S, Becker S, Chan A, Nagaty Y, Naseem S, Schenk J,
Matsuyama K, Baroutsou V. Declaration of Helsinki: ethical norm in pursuit of
common global goals. Front Med (Lausanne). 2024 Apr 2;11
 Green CS. Ethics and Professionalism in Dentistry: A Guide for Students and
Practitioners. Springer; 2012.
 Brandt, A. M. (1978). “Racism and Research: The Case of the Tuskegee Syphilis
Study.” The Hastings Center Report, 8(6), 21-29.
 Klee, E. (1997). “The Medical Case of the Holocaust.” Bulletin of the History of
Medicine, 71(1), 1-18.
 Ralston, J. (2011). “Dental Care and Ethical Issues in Indigenous Communities.”
Journal of Indigenous Health, 7(2), 45-56.

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