International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Review Article

Ethics in Dentistry - A Review

Monika Prasad1, Manjunath C2, Archana Krishnamurthy3, Shilpashree K. B4,
Aishwarya Sampath1, Shefali Jaiswal1, AnkitMohapatra5
1
Post Graduate Student, 2Professor, 3Professor & Head, 4Reader, 5Assistant Professor,
Department of Public Health Dentistry, the Oxford Dental College, India
Corresponding Author: Monika Prasad

ABSTRACT

Background: This article focuses on ethics among dentists. Dental ethics would mean moral duties
and obligations of the dentist towards his patients, professional colleagues and to the society. There
are four basic principles which act as guidelines for decision making.
Findings: Ethics forms an important part of a profession. The code of ethics prescribed by regulatory
bodies as well as professional associations act as a guiding light in distinguishing between the right
and the wrong, observing one‟s duties and maintaining good interpersonal relationships.

Key words: Dentistry, Ethics, Moral, Profession.

INTRODUCTION the conduct of population based research

The word ethics comes from the and practice. Macro ethics can be defined as
Greek ethos originally meaning character or set of principles designed to protect the
conduct. It is typically used interchangeably human dignity, integrity, self determination,
with the word moral which is derived from confidentiality, rights and health of
the Latin word mores, which means customs population and the people comprising them.
[3]
or habits. Together these two terms refer to
conduct, character, and motivations It is intended to heighten ethical
involved in moral acts. Ethics are an responsibility, promote ethical conduct in
unwritten code of conduct that encompasses dentistry, advance dialogue on ethical
both professional conduct and judgement. [1] issues, and stimulate further reflection on
The understanding of ethics can also be common ethical problems in dental practice.
helped by defining some things that ethics is It is not intended to solve specific ethical
not: it is not a set of rules or restrictions, it is dilemmas. So after coming across above
not religion, and it is neither relative nor circumstances, Dentists are strongly
subjective. [2] encouraged to further their understanding of
Dental ethics would mean moral ethics and ethical issues beyond this
duties and obligations of the dentist towards introduction. Dentists should familiarize
his patients, professional colleagues and to themselves with the prevailing laws,
the society. These help support autonomy regulations, and standards that affect their
and self-determination, protect the decisions. [4]
vulnerable and promote the welfare and
equality of human beings. These principles ADA Principles of Ethics and Code of
may be called “micro-ethical” principles Professional Conduct (ADA Code):
where as “macro-ethical” principles guide

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 Monika Prasad et.al. Ethics in Dentistry - A Review

It is, in effect, a written expression of the care and the need to maintain public
obligations arising from the implied contract interest.
between the dental profession and society.
There are five fundamental principles that Nature of Ethical Problems:
form the foundation of the ADA Code: Justification; providing service only when it
patient autonomy, non maleficence, is convenient; refusing to accept
beneficence, justice and veracity. responsibility when treatment fails
PATIENT AUTONOMY (“self- prematurely.
governance”): This principle expresses the
concept that professionals have a duty to How Dentists Perceive Ethical Problems:
treat the patient according to the patient‟s Every clinical, scientific, or legal problem
desires, within the bounds of accepted involves an evaluative component.
treatment, and to protect the patient‟s Evaluation may become an ethical issue
confidentiality. when the dentist realizes that the evaluation
NONMALEFICENCE (“do no harm”): This involves a tradeoff between the value of
principle expresses the concept that reducing pain and other values that the
professionals have a duty to protect the patient may affirm.
patient from harm.
BENEFICENCE (“do good”): This Ethical versus Legal:
principle expresses the concept that People sometimes confuse ethical and legal
professionals have a duty to act for the problems. Both the ethical and the legal
benefit of others and the dentist‟s primary involve evaluations. Ethical evaluations,
obligation is service to the patient and the however, appeal to what is believed to be an
public-at-large. ultimate standard of right and wrong. Legal
JUSTICE (“fairness”): This principle evaluations appeal to the evaluations of a
expresses the concept that the dental particular society. It may be legal for a
profession should actively seek allies general dentists to provide comprehensive
throughout society on specific activities that orthodontic care without adequate training
will help improve access to care for all. but unethical to do so.
VERACITY (“truthfulness”): Under this Ethical issues faced by dentists: the clinical
principle, the dentist‟s primary obligations ethical situations referred to already were
include respecting the position of trust predominantly derived from work done by
inherent in the dentist-patient relationship, Bebeau and Spiedal with a group of
communicating truthfully and without Minnesota dentists:
deception, and maintaining intellectual  Quality of care: Care might be deemed
integrity. [5] inadequate if it involves the delivery of
substandard of care without the patient‟s
Dentistry as reflection of medicine: knowledge, without consideration of the
The recent growth of ethics literature has patient‟s wishes, without justification by
been significant but is nearly 15 years virtue of special circumstances, and
behind medicine in terms of its analysis of motivated by motivational gain.
dental related ethical problems. The  Advertising: The ADA code of ethics
American dental association‟s commission states that “no dentists shall advertise or
on dental education has set standards for solicit patients in any form of
ethics education and has made it a communication in a manner that is false
requirement for accreditation. In clinical or misleading in any material respect”.
dentistry, it has focused on the ethical  Patient autonomy: Issues of informed
standards of the profession in sense of consent and the need to put the patient‟s
concerns for excellence in the quality of interest first are considered very
important. Informed consent is a

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significant dental challenge to the autonomy, (4) the dentists preferred practice
dentist because of the large number of values, (5) esthetic values and (6)
different materials and different efficiency.
techniques available for the same or The patient’s life and general health: The
similar problems. sustaining of life and the promotion of
 Conflicts with patients: One category of overall health is the central concern of all
conflicts deals with those precipitated by practitioners and patients. Under normal
the dentist. For example consider the conditions, dentists should not undertake
patient who is unable or unwilling to treatment that will significantly jeopardize
comply with the home care expectations the life or health of patients. For example, a
of the dentist while the dentist wonders man with malignant hyperthermia who
whether continuation of treatment is received serious facial trauma would have
justifiable. Another category of conflicts risked death had he been given general
with patients includes those precipitated anesthesia for corrective surgery.
by the patient. The most frequent The patient’s oral health: Oral health for the
situation is the patient who requests a purposes of this discussion includes
procedure that is contrary to the training appropriate and pain free oral functioning.
and standards of the dentist. An example What is appropriate functioning on such
is the request for complete mouth factors as age, stage of development,
extraction by a patient who has an general health and the patient‟s
essentially intact dentition that can requirements for function. In the case of a
easily be saved. patient with severe periodontal disease and
 Justice: Several concerns are over issues poor past oral hygiene practices, it is
of justice. What are the obligations valuable to stress the need for more strict
regarding treatment for patients not of home care standards before any treatment is
record who are in pain, for patients with standard.
AIDS, or for patients whose prior The patient’s autonomy: A third concept
treatment has failed. Is the dentist that is valued by patients and dentists alike
obligated provide free services? If so for is autonomy or freedom, in the context of
whom. health care, autonomy refers to the ability of
 Intra professional relationship: Among patients to make their own health care
the most difficult problems are those decisions that reflect their own values and
where colleagues should be confronted goals. If patient, for example, were to
with their incompetence or when request treatment that would appreciably
incompetence should be reported. compromise oral health, “ and if the dentist
 Financial transactions: A final series of acted on the patient‟s request out of respect
ethical issues concerns financial for patient‟s autonomy and did the
transactions pertaining to patients. Some procedure, the dentist would be acting
of these issues involve direct unprofessionally”.
transactions such as requests by patients The dentist’s preferred practice values:
to falsify billing, decisions on who pays. During their formal education, dentists
When treatment fails, the charging of receive powerful messages, regarding
different fees for the same service under choice of treatment that often becomes
varying circumstances. incorporated in their values of preferred
Values in clinical dental ethics: practice. Examples include the restoration
OZAR and SOKOL‟S proposal for six rather than amalgam restorations in
values in dentistry. The values in compromised teeth, and the use of crowns
hierarchical order are as follows: (1) the rather than amalgam restorations in
patient‟s life and general health, (2) the compromised teeth.
patient‟s oral health, (3) the patient‟s

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 Monika Prasad et.al. Ethics in Dentistry - A Review

Esthetic value: Dentists recognise that facial • Not much basis in reality
and intraoral appearances are important to
patients, and they routinely consider esthetic COMMERCIAL MODEL:
factors in their important to patients, and • Dentist has something to sell; patient may
they routinely consider esthetic factors in or may not want to buy it
their treatment recommendations. • Standard "market place" principles apply
Efficiency in the use of resources: • Patient's need for care is not the direct
Efficiency is something that virtually all determinant of the dentist's actions
dentists perceive as essential for operation • Dentist and patient on equal ground
of a successful practice. There is nothing
unprofessional in a dentists working to INTERACTIVE MODEL:
control costs- time, effort, or materials- • Dentist and patient are equal partners
provided the other central values are also • Preservation and maximization of patient
given their due. autonomy
The structure of professions and the • Dentist enhances patient's decision making
responsibilities of professionals: Students capacity
who select the profession of dentistry give a • Dentist contributes expertise into the
variety of reasons for their choice. Among decision-making process. [1]
them are the ability to earn a good income,
the prospect of independent employment THE FIDUCIARY RELATION:
and the opportunity to serve the public. A fiduciary relationship is based on trust
Definition of Profession: The American and confidence that commitments between
College of Dentists defines a profession as parties will be honoured; it exists whenever
(a) an occupation involving relatively long a doctor and a patient establish a
and specialized preparation on the level of professional connection. Because the patient
higher education and governed by a special should be an active participant in the
code of ethics. By contrast, Starr, a relationship, these commitments are a two
respected sociologist of the professions, way street. However, given the unequal
defines it as: “an occupation that regulates knowledge and skills of the two parties, it is
itself through systematic, required training especially important that health care
and collegial discipline; that has a base in provider be worthy of that trust.
technical, specialised knowledge, and that We need to have some basic understanding
has a service rather than profit orientation, of the meaning of morality and ethics.
enshrined in its code of ethics. [6] Moral and non-moral evaluations: a moral
or ethical evaluation must meet certain
RELATIONSHIPS WITH PATIENTS: characteristics:
Doctor-Patient Relationship Models:  Ultimacy: Perhaps the most critical
1. Guide model characteristic of moral or ethical
2. Agent model evaluation is that the standard by which
3. Commercial model the judgement is made is deemed
4. Interactive model ultimate, i.e., there seems to be no
GUIDE MODEL: higher standard by which one might
• Relationship based on dentist's expertise judge. The judgement has what the
and the patient's lack of it philosopher JOHN RAWLS calls
• Patient does not make any contribution to “finality.”
dental decisions  Universality: Moral or Ethical
• Dentist is the judge of the patient's needs evaluations are often also said to be
AGENT MODEL: universal. This means that if other
• All dental decisions made by patient people are considering exactly the same
• Dentist provides service for patient choices action or character trait in exactly the

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 Monika Prasad et.al. Ethics in Dentistry - A Review

same situation. avoiding harm are considered the only

 Altruism or neutralism: Judgements morally relevant feature of actions.
cannot be tailored to the advantage of
the person making the judgement i.e. DENTOLOGICAL THEORIES: Many
cannot be crafted to promote the ethical theories include principles that tend
advantage of the person stating them. to make actions right yet do not focus solely
 Publicity: Another criterion that tends to on maximizing good consequences and
make evaluations moral is that one must minimizing bad consequences. Whenever
be willing to publicly state the the right action, rule, or practice is
evaluation and the basis on which it is determined at least in part by principles
made. other than those that focus on maximizing
 Ordering: Finally, any set of principles, net good consequences, the theory is
rules or character assessments should deontological.
provide a basis for conflicting claims.
The various theories of ethics: PRIMA FACIE DUTIES AND DUTY
PROPER: One‟s duty proper takes into
ALTERNATIVE THEORIES OF account all moral principles, whereas one‟s
NORMATIVE ETHICS: prima facie duty considers only one moral
Normative ethical theories are not addressed dimension at a time.
specifically in studies of health care ethics,
but the basic issues will be similar in any VIRTUE THEORY: We focus primarily
kind of normative ethical theory: on the ethics of actions and therefore must
judgements about which kinds of actions or clarify the principles that indicate what
rules are right (action theory), which non makes actions or practices right, keeping in
moral things are good or bad(value theory mind that we can also assess the virtues of
or axiology) and which traits of character the dentist involved. [6]
are desirable(virtue theory).
DISCUSSION
ACTION THEORY: A theory of right Ethics is a subject which, of
action articulates general principles that necessity, is considered in any and all walks
tend to make actions right or wrong of life either consciously or unconsciously.
according to the ultimate moral standard of It is altered by its environments and
reference. These principles necessarily are everything that goes to make up the
general because they have to be limited to a environment.
manageable number that are understandable According to Thompson HE, in a
to the ordinary person. They are principles profession there is something, whether
such as beneficence, non-maleficence, tangible or intangible, that places service
veracity, fidelity, respect for autonomy, and above material gain, battles all forces which
justice. make for disintegration or demoralization of
our highest ideals, lights in defense of honor
UTILITARIANISM AND of the profession and protection of material
CONSEQUENTIALISTIC THEORIES: and moral welfare of the people. [7]
One major group of theories that is Johnson, in 1946, stated that
particularly dominant in the ethics of health philosophical approaches were better than a
professionals, including dentists, holds that dualistic approach to ethics, which may
what really matters is the consequences of provide dental professionals with the
actions. The dominant principles for such understanding to fashion a more eclectic
theories are beneficence and non- approach to professional personal ethics. [8]
maleficence, where doing good and Brinton, in 1950, stated that ethics
was only a matter of two paths to follow and

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it was intensified by the fact that there was boards, as these were framed almost three
no provision for absolution of sins. decades ago.
Durant, in 1954, stated in his book,
„The story of philosophy‟ that the ancient CONCLUSION
Greek philosophers Plato and Aristotle Ethics in our practice is of immense
viewed ethics as a value to be strived fork, significance today. Ethical values should be
which was the basis of harmony in life and inculcated in every dental student. As a
personal happiness. professional we should:
According to B.F. Skinner, in 1971, 1. Be aware of the responsibilities that
ethics was a matter of performance we accept when entering the dental
discrepancy, devoid of personal values, and profession.
consisting mainly of activities that had to be 2. Meet the standards of competence,
learned by the management of the care and conduct while rendering service.
contingencies. 3. Above all the care of patients should
Nash, in 1984, stated that ethics was be our first concern.
the key to expressing mutual respect among Hence ethics forms an important dimension
people. of a profession. The code of ethics
Warnick BR et al, They propose an prescribed by regulatory bodies as well as
approach to the professional ethics of professional associations act as a guiding
teaching that employs a case-analysis light in distinguishing between the right and
framework specifically tailored to address the wrong, observing one‟s duties and
the practice of teaching. [9] maintaining good interpersonal
There exists a need to teach professional relationships.
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How to cite this article: Prasad M, Manjunath C, Krishnamurthy A et.al. Ethics in dentistry - a
review. Int J Health Sci Res. 2019; 9(3):238-244.

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