Rule / Veatch Ethical Questions in Dentistry

1. Auflage 2019
ISBN: 978-0-86715-925-7
Verlag: Quintessence Publishing Co, Inc
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, 340 Seiten

Updated to reflect the current ethical climate, this book presents clinical practice cases in which arguments can be made for differing courses of action or in which the obligations of the professional are in conflict; the reader is asked to determine the ethically correct response to such conflicts. In this revised edition, detailed background material has been added to many of the cases to foster more well-reasoned ethical decision making. In addition, cases on sexual harassment and advertising have been introduced, and those on financial and HIV issues have been updated. An entirely new chapter on the structure and obligations of the various professions has been added.

James T. Rule, DDS, MS is professor emeritus at the University of Maryland Dental School, where he was chair of the Department of Pediatric Dentistry from 1978 to 1998. His interest in ethics was stimulated by a sabbatical leave at the Kennedy Institute of Ethics at Georgetown University in 1989 and 1990, which culminated in the book Ethical Questions in Dentistry, coauthored with Robert M. Veatch. Dr Rule subsequently initiated a course in professional ethics for dental students and co-founded a graduate course in research ethics for the University of Maryland at Baltimore. He is now retired and lives in Deer Isle, Maine.

Autoren/Hrsg.

Rule, James T.

Veatch, Robert M.

Leseproben

The Influence of Society and Medicine

Society’s Increasing Concern

Ethical standards in modern society are in a time of rapid flux and show the contradictions that characteristically attend such changes. This period of ethical re-evaluation received an abrupt stimulus in the 1960s from the great upheavals over civil rights and the Vietnam War. Contrasted with this is the current widespread concern about the behavior of public persons. A president has been impeached. Congressional ethics committees have taken aggressive action against colleagues. Distrust between political parties is increasingly problematic. Business leaders have been put on trial for deception and dishonesty. Public trust in institutions of all sorts, including most professions, has diminished.1 Consumers are better informed and demand more and better services, including those related to health care. On the other hand, strains of contradictory value systems run throughout society. Large segments of society are becoming more materialistic, more self-serving, less reflective, and less concerned for the welfare of the community.2

Despite these views, there is a growing advocacy for limiting what has been almost a century-long endorsement of unchecked “progress.” Significant portions of the population now feel that the world ecology is at risk, that resources are finite and must be guarded, that technology has created important ethical issues not previously recognized, and that there is something seriously wrong with our health care system, both its cost and its benefits.2

Upheaval in Medicine

Thirty years ago, there was little formal intellectual work that considered ethical questions in the health care professions. What ethical discussion existed was more or less limited to questions about physicians’ practices and how they were interrelated: Should physicians extend professional courtesy? Should they conceal from a patient their disagreement with a colleague’s diagnosis?

During the three intervening decades, medicine’s increased preoccupation with ethics has been phenomenal. The output of ethics literature was minimal in 1970. By 1980 the number of MEDLINE ethics references cited was 313. The number grew to 780 by 1989 and has continued to grow even more rapidly since then. Ethics consultants in hospitals are now commonplace, and most larger hospitals have ethics committees that offer a formal review of problems with ethical overtones.3 In addition, newspapers regularly feature stories illustrating ethical issues involving difficult decisions to be made at the end or the beginning of life.

One of the most important reasons for the growth in concerns over ethics is rooted in the tremendous technological advances that, at great cost, offer prolonged or improved life quality. With high-tech enhancements come questions about who gets the care, who pays for it, and how those decisions are made. Especially important are concerns over genetic engineering, reproduction, and termination of care.4,5

The huge increase in the cost of care is also of special concern. In 1960 the dollars spent on medical care were 5.9% of the gross national product. By 1990 the amount had risen to 12.2%6 and by 2001 to 14.1%.7 Considering the extent of the increase, it is natural to expect citizens to be concerned about ethics. This is especially true when the impact of the dollars spent is questionable. For example, the United States spends two and a half times as much money per capita on health care as does Britain, but life expectancy and other health parameters are quite similar.8

Consider, too, that most medical care is now covered, at least in part, by some form of health insurance. Health insurance in itself generates its own ethical issues. Traditional third-party payment systems encourage overtreatment and overutilization. Health maintenance organizations (HMOs) encourage undertreatment and underutilization.8

Several other factors have contributed to the increased attention or concern about ethical issues. Ethicists have branched out beyond their traditional roles in philosophy departments to enter the health care arena. Undergraduate courses in bioethics and concerns for the ability of future physicians to deal with the increasing complex ethical issues in medicine have set up demands for ethics courses in medical schools that previously had none. Practicing physicians, because of their lack of training in ethics, are often poorly prepared to deal with the ethical issues encountered in daily practice.4

Physicians also have nagging concerns about the desirability of medicine as a profession. Increasing controls by the federal government and by the insurance industry have decreased the time that physicians have available for patient contact. Public trust in physicians is of concern. The nature of medical practice is changing in that more doctors are being employed by organizations. Although physicians continue to control policies in these organizations, they perceive the trend toward “captive” physicians as being undesirable.1 Finally, since 1983, physicians’ incomes, while still very high, have started to decline for the first time.8 These factors, coupled with the decline in the college-age population and the increased attractiveness of other scientific, professional, and business occupations, have led to a decrease in the number of applicants to medical school. All of these factors form a context for the ethical issues that must be faced in today’s society.

Dentistry as a Reflection of Medicine

The recent growth of ethics literature in dentistry has been significant but is nearly 15 years behind medicine in terms of its analysis of dental-related ethical problems. Additionally, although a few books on dental ethics are available, the literature is almost exclusively limited to journal articles, whereas hundreds of books have been written on themes of medical ethics. Until 1993, when the first comprehensive books on dental ethics were published, the only applicable book available was limited to issues of informed consent.9

Still, there is a rising interest in ethics in dental education. The American Dental Association’s (ADA’s) Commission on Dental Education has set standards for ethics education and has made it a requirement for accreditation. In addition, all dental hygiene schools10 now have courses in professional ethics. However, the ability of these courses to stimulate valid ethical reasoning may be of concern because few of the faculty have formal training in ethics.

In clinical dentistry, the interest in ethics is considerably different from that of medicine. For example, there is nothing comparable to the ethics consultants or ethics committees that are becoming routine in the hospital practice of medicine. The main consideration in dentistry has not been about specific clinical issues such as that of the termination of care. Rather, it has focused on the ethical standards of the profession in the sense of concerns for excellence in the quality of care and the need to maintain public trust. The leadership in this regard has come from the American College of Dentists. The growing number of ethics-oriented continuing education courses is a reflection of those concerns.

Some of the ethical issues in clinical dentistry derive from technological advances that have somewhat paralleled those in medicine, although with fewer dollars at stake and less involvement in life-sustaining issues. Nevertheless, costly innovations such as computer-generated restorative procedures (ie, CAD/CAM), along with the increasing use of implants and lasers, not only serve to improve the quality of care but also make care more inaccessible to less affluent people.

The increases in costs of care in dentistry have been substantially less than those in medicine, but they still present ethical concerns in terms of the resulting benefits. In medicine the huge increase in costs has not improved morbidity or mortality statistics. In dentistry there has been a steady decline in caries rates in children and young adults over the last 40 years and a decline in periodontal disease as well. However, these improvements appear to be related less to patient care provided by dentists than to water fluoridation and the increased use of improved oral home care products, especially fluoride dentifrices and therapeutic mouthrinses.

In another parallel with medicine, the growth of dental health insurance has been significant. However, it has not reached the high level of coverage experienced for medical insurance. Statistics from 2000 show that 85.4% of the population had some form of general health insurance, whereas only 57.4% had some form of dental insurance coverage.11 Nevertheless, the entrance of insurance into dental practice has fostered significant ethical concerns about overtreatment and undertreatment, just as it has in medicine.

Medicine is becoming more concerned over its public image and its desirability as a profession. Dentistry, always sensitive to issues of public opinion and professional status, has also experienced some recent decline in that regard. The 2001 Gallup Poll on honesty and ethics in American professions placed dentistry eighth from the top, below nurses, pharmacists, veterinarians, physicians, grade-school and high-school teachers, and clergy, and immediately below college teachers.12 While eighth is not bad, it is several steps down from the top two or three rankings, where dentistry stood for decades. In one of his monthly commentaries in the Journal of the American Dental Association,...