Legal Ethical Dilemma

Transcription

1 Legal Ethical Dilemma Jen Sandstrom, Marta Rewako, Michelle Vu, and Lindsey Cetani Foothill College Spring 2014

2 Introduction Throughout our career as dental hygienists, we will face many legal and ethical dilemmas. The dental hygiene Code of Ethics is set in place to help guide us to reach the most ethical resolution possible. Combined with critical thinking skills, implementation of ethical principles will help avoid any legal repercussions and minimize potential harm caused to persons involved. The ethical dilemma my group and I worked on solving involved a new dental hygienist working as a temp in a dental office. A new patient comes into the office presenting with a severe periodontal condition. After thorough assessments are performed, the dental hygienist determined that 4 quadrants of scaling and root planning is indicated; however the supervising dentist just wants the dental hygienist to perform a gross debridement and finish the patient s treatment in the hour time allotted. This poses major ethical and legal implications as the dental hygienist tries to figure out how to best resolve the dilemma. Ethical Dilemma Scenario/Identify the Problem Solving an ethical dilemma can be very challenging. The best way to learn how to solve an ethical dilemma is to look at an example of one. Consider the following incident: Fran Furca is temping in a dental office as a dental hygienist. A new patient comes into the office presenting with generalized heavy supra and subgingival calculus. They also exhibit several deep pockets of 5mm and greater, as well as generalized bleeding upon probing. After thorough assessments are performed, Fran Furca determined that 4 quadrants of scaling and root planning is indicated. She knows she will need longer than 1 hour to complete the patient, and notified the supervising DDS of her treatment plan. The DDS then tells her that he does not agree with her treatment plan and tells her to complete a regular cleaning for the patient in the allotted time. Fran Furca tries to decide what she should do next. Research When an ethical dilemma arises, there are several principles that are set in place to help guide and resolve issues. As dental professionals, there are also basic core beliefs that

3 one should strive to uphold and adhere to. The Code of Ethics is the guiding force regulating the actions of every dental hygienist. It is the responsibility of the dental hygienist to recognize the guidelines for making ethical choices and knowing and applying them appropriately. As dental professionals, it is our duty to accept the consequences of our actions, as well as the failure to act and publicly assert them. 1 To act in an ethical manner means to act out of the best interest of society, and treat all individuals as autonomous beings. If Fran Furca were to perform a gross debridement on the patient that needs scaling and root planing, she would be acting unethically. One ethical principle she would be acting against would be that of nonmaleficence. Fran Furca would ultimately be causing the patient harm, and it is the obligation of the dental hygienist to provide services to a patient that minimizes harm and adverse outcomes. 1 If gross scaling is performed, the patient may end up returning a week later with extreme pain and several periodontal abscesses from the treatment. Nonmaleficence, asserts an obligation not to inflict harm intentionally. Although the dentist is ultimately responsible for the actions of the dental hygienist, the dental hygienist still may be found negligent in a court of law if a required duty is not met. 9 Current research suggests and supports that performing a gross debridement of the periodontium will actually cause more harm than good. 6 Periodontal diseases are infections that are initiated by bacteria, and partial removal of the biofilm and bacterial pathogens will do little to reduce the generalized infection. Partial removal of large deposits of calculus in which bacterial pathogens flourish can increase the occurrence and prevalence of new periodontal infections such as abscesses. 6 The pathogenesis of this infection occurs due to invasion of bacteria into the soft tissue pocket. Leukocytes and inflammatory infiltrate are the biggest factors associated in the destruction of supportive connective tissue and the formation of exudate. 7 Tissue resistance, virulence, and host response all contribute to the formation of a periodontal abscess. 7 In accordance with nonmaleficence, it is also the ethical duty of the dental hygienist to follow the principle of beneficence. Beneficence means doing what will benefit a person. 5 According to the IFDH Code of Ethics, the dental hygienist s own personal interest, in conflict with the his/her professional obligations should be declared and resolved for the well-being of the client. 5 By not performing a gross debridement on the patient, Fran Furca

4 is acting according to the standard of care and out of the best interest of the patient. 1 Informing the patient of their periodontal condition is also acting out of beneficence for the patient. As patients are becoming more concerned with their oral health, failure to diagnose or treat periodontal disease is the fastest growing area of litigation in dentistry. 2 It may seem obvious that the patient would know about their periodontal health; however it should never be assumed. Each patient should be treated equally and with comprehensive care, as research is becoming more extensive on the oral-systemic health link. There are certain circumstances when an ethical dilemma can coincide with legal offenses. Legal principles that can be violated when it comes to this ethical dilemma are informed consent, negligence, and malpractice. In accordance with California law and avoiding malpractice, comprehensive approaches to a complex periodontal case need to be made aware to the patient. When formulating a treatment plan, all of the risks, benefits, alternatives, cost, and long term consequences need to be understood by the patient before they consent to receiving any treatment. 2 Informed consent plays a major role in legal litigations, and is the general duty of the healthcare provider to inform and advise their patients of all of the material risks of a proposed treatment. 3 A material risk is defined as one that a reasonable man would consider when determining whether or not to proceed with the proposed treatment course. Patients can sue dental professionals if they feel that they haven t been fully informed of their oral hygiene status and were not provided with treatment procedures up to the standard of care. 3 More commonly sought than issues regarding informed consent are issues involving acts of negligence by dentists. Negligence involves four areas of which include duty, breach of duty, proximate cause, and injury; with the most common element advanced by patients being that of duty. 3 Duty by a dentist is defined as applying the knowledge, skill, and care that is ordinarily provided by dentists in the local area which they practice or in similar cases and under similar circumstances. 3 This ultimately states that the dental treatment issued to the patient must be in accordance with the standard of care for that area, and any treatment that deviates from such standard would be considered a breach of the duty owed to the patient. 3 Options and Alternatives

5 Fran Furca is faced with a tough decision, and many options to this ethical dilemma exist. She must consider the legal, social, and ethical aspects of treating her patient, and determine the best solution. Listed are three outcomes that could occur based on what the dental hygienist determines is the most ethical and logical choice. a. Dental hygienist told by DDS to proceed with a routine prophylaxis/supra gingival gross scaling. The patient returns with infection of many periodontal abscesses. b. Dental hygienist doesn t agree with the decision of the supervising DDS and refuses to perform a gross debridement of the patient, putting the dental hygienist s job at risk. c. Dental hygienist completes as much scaling as they can on the patient in the allotted time given and informs the patient that they will need to make another appointment(s) to complete the cleaning. Dental hygienist s job is put at risk. The first scenario would be for the dental hygienist to proceed with the dentists recommended treatment and perform a gross scaling procedure. As dental hygienists, we know that the patient is truly in need of scaling and root planning and a gross debridement can allow for harmful risks to arise. For a dental hygienist that performs gross debridement on a patient that needs scaling and root planing, they are negligent of the risks associated with performing care that is substandard. The next option is to go against the supervising dentist s recommendation, and decline any dental hygiene care for the patient. This would likely mean that Fran would upset the dentist by going against his suggestion, possibly risking losing her job. However, she is a new dental hygiene graduate, with minimal experience and does not want to lose her job. She is also in need of the money, as she needs to pay off her student loans. She is very uncertain as to what to do in this situation because she really needs a job, but knows she has to do what is right. The last alternative is for the dental hygienist to use the one hour appointment to scale one or two quadrants and thoroughly remove all calculus deposits in the areas. This would be going against the dentist treatment plan of performing a gross scaling procedure. Although Fran Furca believes this is a better alternative than a gross scaling procedure, as it

6 would benefit the health of the patient, it is still going against the dentist s advice. Changing the treatment could also upset the dentist and put her at risk for losing her job. Best Solution The best solution for correcting the problem would be to explain to the supervising dentist that she does not feel comfortable performing a gross debridement procedure. Fran believes that the health of the patient would be compromised and does not feel it is ethical to perform such a treatment. Although the dentist may not agree with her, and may even terminate her job position, she knows that this is the best option. Justification of Decision and Action Fran Furca realizes that although she does not want to lose her job, her ethical standards and personal values would be compromised if she performed the gross scaling procedure. She would instead decline the dentist s suggestion and educate the patient on their periodontal status, by discussing the increased pocket depths, calculus levels, and what their radiographs reveal. Evidence based treatment modalities can be discussed with the patient, so that they have a better understanding of the situation. Discussing all risks and benefits of the scaling and root planning procedure can help aid them in the process of deciding to undergo treatment. As a dental hygienist, Fran decides that the ethical principal of maleficence, to do no harm, would be compromised if she performed a gross scaling. Beneficence would also play a role because it is her obligation to do good, by advising the patient of their condition so that they are educated on their health status and can make their own decision on the treatment plan. Implementation of Decision After thinking the process through, Fran Furca excuses herself from her patient for a few moments and asks to speak with the dentist. They meet in his office and decide to take some time to talk about the issue at hand. Fran explains her ethical dilemma, sharing that she does not feel comfortable performing a gross scaling on the patient, and lists the several reasons why. She states that she will not perform the procedure, and that she prefers to take

7 the remainder of the appointment to educate them on their periodontal status and perform oral hygiene instructions. Even though Fran is nervous she will lose her job, she knows that this is the right thing to do. Although the dentist has the ultimate decision as to what will happen next, informing the dentist of the situation may help them understand what the standard of care is for dental hygienists.

8 References 1. American Dental Hygienists Association: Bylaws Code of Ethics. Chicago (IL). Available from: pdf; p Baker P, Needleman I. Risk management in clinical practice: part 10 periodontology. British Dent J. 2010; Dec: 209(11): Nora, Robert L. Dental malpractice: its causes and cures. Quintessence International. 1986; 17(2): California dental practice act 1950(s) business and professional code section ). Available from: group= &file= Kimbrough-Walls Vickie J, Lautar Charla J. Ethics, jurspriducence, and practice management in dental hygiene. 3 rd ed. Alexander Julie L. Upper Saddle River (NJ): Pearson Educaiton Inc; p Nathe, Christine. A quick fix to access to care. RDH Magazine. March 2010; p Bhusari BM, Sanadi RM, Ambulgekar JR, Doshi MM, Khambatta XD. Abscesses of the periodontium: review with case series. Indian Journal of Dental Sciences Dec;5(5): National Institute of Dental and Craniofacial Research. Periodontal Disease: Causes, Symptoms and Treatment. NIH Publication No August 2012, available from: ase.htm 9. Darby, Michele Leonardi, Walsh, Margaret M. Dental hygiene theory and practice. 3 rd ed. Dolan, John J. St. Louis (MO): Saunders Elsevier; p