ANSWER :
The American Dental Association Principle of Ethics and Code of Professional Conduct ( ADA Code ) provides helpful insight when a dentist is presented with a complicated dilemma such as the one described . Questions about the allocation of resources , patient autonomy , surrogate decision making , and professionalism all converge . For example , would recommending expensive dental treatments in a patient with metastatic cancer be an appropriate use of resources ? How should the dentist honor patient autonomy while honoring the wishes of the family , who may know more regarding the patient ’ s best interests ? Does the patient have capacity ? If not , who is the patient ’ s surrogate decision maker ?
The ADA Code calls on dentists to prioritize patients ’ interests . 1 According to the ADA Code , “ Qualities of honesty , compassion , kindness , integrity , fairness and charity are part of the … practice of dentistry and help to define the true professional .” 1 Each of those qualities is necessary for addressing the circumstances presented in the scenario described . In addition , the core ethical principles of Patient Autonomy (“ selfgovernance ”), Nonmaleficence (“ do no harm ”), Beneficence (“ do good ”), Justice (“ fairness ”), and Veracity (“ truthfulness ”) must be followed .
To respect patient autonomy , the dentist must consider patient values and personal preferences in treatment decisions . 1 In making the determination in this case , the dentist may find it helpful to determine whether Sarah has decisional capacity . If not , then determining whether she has designated a power of attorney ( POA ) for health care may be necessary . If no POA has been named , determining who her surrogate decision maker is will be based on state law .
As previously mentioned , the ADA Code calls on dentists to prioritize patients ’ interests 1 using “ Qualities of honesty , compassion , kindness , integrity , fairness and charity ....” 1 The option of remaining silent or not telling Sarah the truth about the diagnosis could cause harm to the patient . Therefore , this action violates the principles of Veracity and Nonmaleficence . The principle of Nonmaleficence under the ADA Code states ,
The ethical dentist strives to do that which is right and good .”
“ The dentist has a duty to refrain from harming the patient .” 1 Not following Sarah ’ s wishes may cause dignitary harm by ignoring her autonomy ; however , given her condition and her family ’ s input , proceeding as she asks may cause physical or psychological harm . Given this concern , Section 2 . B ., Consultation and Referral , of the ADA Code may be relevant . Under this section , the dentist is obligated “ to seek consultation , if possible , whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills , knowledge , and experience .” 1 In this instance , that might necessitate speaking with Sarah ’ s oncologist or her primary care provider .
According to Welie2 and Welie and Welie , 3 autonomy hinges on the patient ’ s capacity . Respect for a patient ’ s autonomy is conditional on the patient ’ s ability to understand the risks , benefits , and alternatives of the requested or proposed treatment . According to Mukherjee and colleagues , 4 “ Capacity implies the physical and cognitive ability to participate fully in the informed consent process .”
If the treating dentist feels Sarah has the decisional capacity , the dentist will need to consider how to best respect the family ’ s concerns . Under the principle of Justice , “ The dentist has a duty to treat people fairly .” 1 Therefore , being fair to the family is essential , but if the patient can make her own decisions , her choices are what should guide the actions of the dentist .
If , however , the patient lacks capacity , a durable POA for health care or a surrogate decision maker can extend the patient ’ s autonomy , under which judgments or decisions can be made on the patient ’ s behalf . 2 When applying substituted judgment , however , the decision maker is asked to make the decision the patient would have made had they possessed the capacity to do so themself .
In summary , if the patient has capacity , then the dentist first and foremost must involve the patient by being sure to “ inform the patient of the proposed treatment , and any reasonable alternatives ....” 1
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MARCH / APRIL 2023 | PENNSYLVANIA DENTAL JOURNAL 21