In the last two articles we discussed the six central values of dental practice. Beginning with the most important, they are:

1.  The patient's life and general health

2.  The patient's oral health

3.  The patient's autonomy

4.  The dentist's preferred patterns of practice

5.  Esthetic values

6.  Efficiency in the use of resources

We prioritize these values in the order in which they are listed each and every day in our practices whether consciously or not. Often they conflict. The following case is a simple one in which the first four of these values do just that.

Case In Point

Mrs. Johnson came to Dr. Ethics' office in considerable pain. An upper premolar was abscessed. It needed immediate care to relieve her pain. The long-term alternatives were either root canal therapy and a crown, removal and a prosthessis, or simple removal.

Mrs. Johnson was a regular patient of Dr. Ethics', a widow in good health, without much money, and having no dental insurance. She had conveyed her financial status to Dr. Ethics several times over the course of previous appointments.

What are Dr. Ethics' obligations?

The placement of the patient's oral and general health as first on our list of values demands Dr. Ethics address Mrs. Johnson's pain as top priority. Only when Mrs. Johnson is out of pain can she make a thoughtful choice about her long-term care. If Mrs. Johnson was in the office on an emergency basis, tucked into a normally busy schedule, she may need to be rescheduled to discuss her "permanent fix" if only because she may not be in the right frame of mind. Pain is a "significant inhibitor of the exercise of autonomous choice."

But what if Mrs. Johnson wants to hear the pros and cons of her choices anyway in the midst of such a schedule? Then Dr. Ethics needs to consider the oral and general health of his other patients as well, above the autonomous choice of his emergency patient.

Now let us suppose Dr. Ethics was able to relieve Mrs. Johnson's pain and was able to reappoint her to discuss her treatment options. That brings us to her financial situation, which has still not improved. What will guide Dr. Ethics' conversation with Mrs. Johnson? First, Dr. Ethics cannot recommend or do anything that would compromise Mrs. Johnson's general or oral health. The value of the patient's autonomy requires a full explanation of all treatment options, including "none at all" if appropriate. More is required here than just informing, however. Dr. Ethics must not only work to avoid violating Mrs. Johnson's autonomy, he must work to enhance it. A patient's choice is often hindered by finances, so if Dr. Ethics can ease Mrs. Johnson's financial difficulty, it would enhance her autonomy — i.e., offering a payment plan, perhaps offering a discount, maybe bartering for services. Of course, "a patient's oral health depends significantly on correctly understanding relevant facts." Dr. Ethics must educate Mrs. Johnson. Ignorance or misunderstanding leads to fear, which limits our patient's autonomy after the relevant discussion.

What if Mrs. Johnson chooses a treatment inconsistent with Dr. Ethics' philosophy of practice? Since "preferred patterns of practice" ranks below our patient's autonomy on the values list, it would seem Dr. E would have to provide a treatment which violates his practice philosophy. What then? A referral to another practice may be an option. If this is not an option, however, and the central values of the patient's life, general, and oral health are not violated, then Dr. E is required to present to Mrs. Johnson all of her options, perhaps recommend one, and provide the chosen treatment if within his competence. He may not refuse to provide this treatment. In this way, the hierarchy of values does put constraints on the choices a dentist can professionally make. As noted, then, a patient's care is dictated by an intertwining of the doctor's and the patient's choices.

Until next time...

*Dr. Churchill is Chair of the Minnesota Dental Association's Committee on Ethics, Bylaws, and Constitution.  He is a general dentist in private practice in Minneapolis, Minnesota.

**Ideas and material quoted in this article are from Dental Ethics at Chairside:  Professional Principles and Practical Applications by David T. Ozar, Ph.D. and David J. Sokol, D.D.S., J.D., F.A.G.D., Georgetown University Press, Washington, D.C.

Please e-mail us at kdegrote@mndental.org or fax us at (651) 646-8246. We look forward to hearing from you not only regarding this article, but also if you have any ethical dilemmas you would like to present to the membership. Perhaps we can help you decide what to do.