Olivier Hamel (1), Christine
Marchal (1), Michel Sixou (2), and Christian Hervé (3)
(1)
Laboratory of Medical Ethics and Public Health, Faculty of Medicine
Paris-Necker, France. Dental Faculty of Toulouse,
France.
(2) Dental faculty of Toulouse, France
(3) Laboratory of Medical Ethics and Public Health, Faculty of Medicine
Paris-Necker, France.
Thinking about ethics in dentistry, whatever for?
Abstract
Odontology is
claiming its autonomy in the medical universe. Ethical reflection in medicine
has been developing since the beginning of the nineties. Some points are
developed to involve such a reflection in dentistry: the patient/practitioner
relationships, the necessity of the reflection, the need for openness and
clarity, the notion of public health, the professional purpose of each of us.
The prospects and the aim are to propose ways of improving the teaching of
ethics. Odontology cannot sidestep this process of reflection.
Keywords
Ethics, odontology, teaching
Introduction
What useful
purpose could it serve? Surely odontology is essentially concerned with
answering patients' questions on function, pain and aesthetics1. What
place can professional arguments hold in a quasi-philosophical debate? We shall
try to establish the involvement of professional odontologists in this issue.
The answer necessarily includes the ethics of practice.
First point: A
complete change of relationships as far as treatment is concerned, and an
increase in its technical nature. Medical paternalism has had its day. No
longer can the treatment relationship be seen as a meeting between the
conscience of the giver and the confidence of the recipient2. The
concept of a shared decision has come to be accepted and is backed up by law
(e.g. the French law of 4th March 2002)3.
Obtaining the patient's informed consent, which has become a true negotiation,
remains an important requirement. But the essential factor now is that the
practitioner has the possibility of proving the information he provides. The
elements presented to the patient to convince him to follow one course of
treatment or another must be supported by concrete facts if necessary, including
information on possible negative consequences. In parallel, the technical aspect
of the art of dentistry has made spectacular progress in recent years. How can
the dentist, with his duty to give clear, complete information, take on his
responsibility?
The patient's signature on a formal document is not a particularly convincing
element. The major, indispensable tool to provide a suitable response exists: it
is the patient's medical record. The contents of the record now provide, within
the logic of this new health democracy, a means of following the dentist's
efforts to clarify his explanations and the decisions to be taken4.
In addition, the number of healthcare professionals working in cooperation for
the same patient is increasing: biologists, radiologists, orthodontists,
implantologists, periodontists and, of course, the family doctor may all be
involved. The contents of the medical record are thus shared, a priori
for better patient care. The patient himself, however, faced with all these
"specialists" using his records at his request, may feel lost. He is sometimes
torn between the proposals he has for treatment and the comments of the
organizations that are required to pay for it. The latter, bound to certain
practitioners by agreements, tend to orient their members towards more
"controlled" offers of treatment5. The role of the dental surgeon
responsible then becomes central. A personalized medical and/or odontological
record enables the work of the various medical and paramedical participants to
be coordinated around the central element: the patient.
Second point: The
ethical reflection necessary for odontologists. Ethical reflection and
social reflection are interwoven in the humanitarian movement of the past 30
years6. The response of dental surgeons, as healthcare professionals,
to the needs of our fellow citizens has been clear in terms of technique and
competence. But beyond this, is it not necessary to ensure that our practices
respond adequately in the way our patients are welcomed and respected? Do we
satisfy the expectations of those who are or would like to become our patients?
Indeed, should we content ourselves with satisfying their requests? Why does
prevention not appear more often as a major ethical objective? Prevention can
only be applied after reflection on the values that justify the profession of
dental surgeon, the values that form the basis of the behaviour (including the
patients’ respect of prescriptions) and social intercourse, notably solidarity,
through which all types of treatment are given free of charge or reimbursed.
By participating in this democratic debate, the practitioner, prompted by his
reflection on medical ethics, within the framework of odontology, takes an
active part in promoting the quality of such intercourse. In bringing together
the conditions necessary for such a democratic debate, the healthcare
professional cannot act alone. It is his duty to construct his ethical
reflection on his practice with representatives of the other disciplines:
economics, law, sociology, psychology, philosophy, etc7. Odontology
and medicine are then enriched by the contribution of these disciplines to the
reference for ethical reflection on their practices.
Third point: The
need for openness and clarity. Faced with the media which put forward,
sometimes with much ado, a certain image of our profession, an attitude of
openness is a necessity. This attitude, based on the reality of our practice and
an explanation of the complexity of our treatment, should complete the
individual discussion between practitioner and patient and extend it to the
community. As far as medical cases brought before the courts are concerned,
"dental" cases are well placed, just behind nosocomial infections and
complications after surgery. The specificity of this odontological litigation is
that it rarely concerns medical errors or technical faults but most often has to
do with questions of information, consent and cost. The need for openness and
clarity is also expressed through the legal system as the outstanding value
necessary for a person to be considered to be in full possession of his legal
autonomy. But do all those coming for a consultation at a dental surgery really
have this autonomy? The whole discussion on a mild, or even equally distributed,
degree of beneficence (condemned in the past as exclusive, or as paternalism)
then comes to the fore. Dentistry, like psychiatry, still conveys a whole range
of imaginary concepts for our fellow citizens.
Fourth point:
Convincing practitioners that they are public health clinicians. This must
be carried out within action in favour of the individual's appropriation of his
own body and his "health" capital. Dentists mostly work in independent
practices. Alone and poorly informed, they cannot, in such conditions, always
take up the challenges of public health (access of the disabled or elderly to
treatment, multidisciplinary patient management – cardiology and odontology for
example). The dental surgeon is a true co-worker for all medical personnel, as
the development of networks of independent practices and hospitals demonstrates.
These provide a response to a diversity of situations (e.g. palliative care)
where private practitioners and the hospital organization have succeeded in
pooling competence which, used separately, would prove insufficient.
In this new way of apprehending the links among the various health professions,
the unifying element, at the centre of the relationship, is the person in need
of help. He has chosen to entrust himself to our care!
Fifth point: Avoiding impersonal
professionalism. Medical ethical reflection appeared when medicine became
increasingly technical. Odontology cannot ignore the risk of its technical
aspects becoming dominant with a form of hyperspecialization. Admittedly, it
seems of prime importance to keep the reality of a dental surgeon being a good
technician but it is equally indispensable to have practitioners who are more
and more human thanks to their initial and in-service training insisting on the
psychological and existential aspects inherent in the relationship with a person
who is unwell.
As for medical doctors, who perhaps discovered it to their cost, it is necessary
to introduce dental surgeons to a new conception of their profession. They must
learn to consider odontology as a social practice like any other. As such, it
becomes one of those practices that cannot exist purely on their own account.
Thus we see the interest of integrating it in the social practices that form the
framework of our society, the regulation of which is democratic. It is in this
sense that the concept of “medical democracy” takes on meaning: the health
professional participating in the evolution of the social rights that form the
foundation of the social justice of a nation. Thus this ethical reflection
as a whole includes the question of each individual's professional purpose: it
is the very essence of any reflection on ethics.
Sixth point: Prospects.
Making odontologists aware of ethical questioning pre-supposes reflection on an
inventory, never exhaustive, of the themes to be tackled. It then points to the
question of a framework for the training: when, how and where? Among the "odontological
ethics" subjects, let us mention:
- Exclusion
from or access to treatment: What is the response offered by the health
system? What is the response of the dentist confronted with the need for
preventive or curative action?
-
Information and consent8: What is the reality in human terms of
consent that can very rapidly become administrative?
- Fees:
These pose the question of the quality of the profession of dentist. It is
not surprising that, like anyone else, he should be called upon to justify
them. But it is legitimate to maintain individual fees corresponding to
treatment (preventive or curative) which, itself, must be justified because
of the necessity to balance the budget of the system paying for the
treatment9. In France, however, long standing neglect of useful
treatment, particularly dental and optical care, has led the country to
support the existence of a system that has become iniquitous.
- Pain: To
what extent is it the result simply of the techniques or drugs used in the
treatment, when there is known to be a strong link between the recognition
given to an individual and his perception of pain?
- The
care relationship: Has the dentist taken on board the new dimension of the
patient as aware and autonomous, and thus as a full participant in the
treatment?
- The place
and role of institutions (hospital, bodies responsible for payment,
professional unions, etc.): What capacity does each have to promote
discussion based on objective assessments of odontological practice without
taking a corporatist standpoint?
- Social
and professional implications: These question the part the dentist plays in
determining health policies. Is he ready to consider "dental-social" aspects
in addition the purely "dental"?
- The
dentist's ethical aims: The dentist is required to situate his action
between a refusal to medicalize problems that are essentially social and an
obligation to provide treatment.
As far as the
practical organization of this approach to ethical reflection is concerned, the
following questions merit consideration:
- When?
Before, during and after the degree course, to help the citizen dental
surgeon to continue to flourish and develop throughout his professional
career.
- How?
Through multidisciplinary discussion based on the evaluation and analysis of
practice.
- Where?
Hospital and university are legitimate structures. More open structures can
be imagined: "Ethics Centres" for which a geographical (local community,
town, region, etc.) and human range of action would have to be
defined. Such places would thus have to be able to cater for all the
practitioners, patients' associations, and patients themselves. Above all,
they would be places for thinking about humanity.
Conclusion
Odontology, a branch of medicine in its own right,
cannot sidestep this process of reflection, which should stimulate all those
involved in the field of health, including sick people or their representatives.
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Correspondence
Address:
Dr Olivier Hamel
Public Health Department
Dental Faculty of Toulouse
Paul Sabatier University, 3
chemin des Maraîchers
31400 Toulouse
France
e-mail:
hamel@cict.fr