Dentalcare CE528 Ethics in Dentistry Part II – Codes of Ethics User Manual

Dentalcare CE528 Ethics in Dentistry Part II – Codes of Ethics

Course Author(s): Phyllis Beemsterboer, RDH, MS, EdD, FACD
CE Credits: 2 hours
Intended Audience: Dentists, Dental Hygienists, Dental Students, Dental Hygiene Students
Date Course Online: 05/01/2017
Last Revision Date: 05/23/2023
Course Expiration Date: 05/22/2026
Cost: Free
Method: Self-instructional
AGD Subject Code(s): 555

Online Course: www.dentalcare.com/en-us/ce- courses/ce528

Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.

Note to Iowa dental professionals: This course does not comply with the Iowa Dental Board for recertification in the area of Iowa jurisprudence, as established by the Centers for Disease Control and Prevention (CDC).

Conflict of Interest Disclosure Statement

• The author reports no conflicts of interest associated with this course. She has no relevant financial relationships to disclose.

Short Description

This course will explore a code of ethics as one of the essential characteristics of a true professional. Dentistry is granted privileges when providing care to the public and in return the profession should adhere to high ethical standards of conduct. This course is a guideline for the attainment of goals and aspirations of the profession as a tool for awareness, reflection and self-regulation.

Please note this is Part II of a three-part series. To gain the full benefit of the concepts covered in this course, be sure to read Ethics in Dentistry: Part I – Principles and Values and Part III – Ethical Decision making.

Overview

This course will explore a code of ethics as one of the essential characteristics of a true professional. Dentistry is granted privileges when providing care to the public and in return the profession should adhere to high ethical standards of conduct. This course is a guideline for the attainment of goals and aspirations of the profession as a tool for awareness, reflection and self-regulation. The role of codes and their effectiveness will be explored in the practice of dentistry and dental hygiene.

Learning Objectives

Upon completion of this course, the dental professional should be able to:

• List and define the purpose of a code of ethics. Describe the development of codes of ethics in health care.
• Compare and contrast the codes of ethics of dentistry and dental hygiene.
• Discuss the role of codes as a contract with society.

Introduction

The professions of dentistry and dental hygiene each have a discipline- specific code of ethics. These codes describe the goals, aspirations and subsequent ethical standards of each group. The purposes of these professional codes of ethics are to bind the members of the group together, define expected standards of behavior and as a tool for self-regulation of its members. Codes are a touchstone by which all members of a profession can judge the acceptable parameters of behavior. More importantly, the code is the contract that the profession as a whole makes with society outlining the standards it will strive to uphold.

Professional Codes in Health Care

Ethical codes address the areas of personal integrity, dedication, and principled behavior.1 Health care professionals cherish and hold sacred the obligations that come from the study and subsequent entrance into a learned profession. The prescribed principles and standards of behavior codify and reinforce the significance of being a part of a special group of people who are committed to the same values and goals.

Three things demonstrate how codes can be effective in shaping professional behavior.2 First, when professional schools of health care screen applicants for admission to educational programs, integrity and character are an important criteria for acceptance. Admissions committees strive to select candidates who are the best qualified academically as well as candidates of good character. Virtues and virtue ethics, derived from the writings of Plato and Aristotle, are simply praiseworthy traits of human character. A virtue is a character trait; the assumption is that if a person is virtuous he or she will act virtuously. Thus, part of the selection process often focuses on identifying virtue in the character of applicants and explains why letters of recommendation are often part of the admissions process in the health care professions. Secondly, each entering student is assumed to have the character traits needed to be a true professional and the willingness to uphold the established values. Educational institutions actively seek to indoctrinate students to the goals of the profession and expected professional behaviors. Learning what is expected of that profession reinforces character traits in the developing professional. This often is accomplished by introducing students to the institution’s code of conduct, by familiarizing them with the profession’s code of ethics and professional conduct, and by faculty serving as positive role models. The now common practice of holding a White Coat Ceremony at the beginning of medical or dental school is a method of establishing expected professional duties and behaviors in a public and demonstrative manner.

Third, after entering professional practice, it becomes the obligation of the newly trained individuals to help regulate their profession. Members of the profession who become aware of code of ethics violations have a duty to intervene in a substantive way. This is an important duty and must be carefully considered; the reputation of the profession and the well-being of the public ultimately rest on a willingness to engage in meaningful self policing of the profession.

Professional groups and the public have sometimes questioned the value of codes of ethics. Do codes of ethics really make a difference in the way health care providers interact with and treat patients and colleagues? If a member of a profession has seen evidence of colleagues acting unethically and those colleagues have not been dealt with, that question is legitimate. It would be the same for a member of the public who has had a poor experience with a health care professional or health care system. The patient may assume that he or she was treated in a manner inconsistent with the standards of behavior in the profession (even though the professional may have behaved appropriately). Sometimes the act may be inappropriate behavior by the professional; conversely, the frustration of the patient may lead him or she to believe unethical behavior occurred even when it has not. A bad outcome from treatment does not necessarily indicate unethical conduct.

The degree to which codes are effective remains a difficult question to answer completely. However, because health professions invest so much effort in the development and propagation of codes of ethics and standards of professional behavior, an assumption that the professions find them to be extremely valuable is reasonable. When violations of the code occur, the profession is empowered to take action to resolve the problem. Although codes alone do not guarantee that everyone will behave with integrity, they do provide guidance and standards by which professionals can be judged.  A code of ethics does serve as a tool in the function of self-regulation.

Codes serve as a touchstone by which all members of a profession can judge the acceptable parameters of behavior. This is why being a professional person is a privilege and carries both benefits and burdens – responsibilities that must be met to uphold the elements of a true profession.

Development of Ethical Codes

The first ethical code dates back to the time of the Greek physician Hippocrates, and the influence of the Hippocratic traditions and writers of his time is still reflected today in modern versions of ethical codes. Traditional medical codes of ethics emphasize the physician’s (1) duties in the individual patient physician relationship, including the obligation of confidentiality; (2) authority and duty of beneficence (i.e., acting for the patient’s good); and (3) obligations to each other.3 In return for the power and prestige granted to the professions, a code of ethics is the promise to society to uphold certain values and standards in the practice of the profession. They typically are powerful ethical statements, but they are not legal mandates. However, codes cannot easily be dismissed if there is a formal structure for self-regulation. Because state boards typically have the authority to suspend or terminate a professional’s right to practice, the fact that more attention is being given to ethical behavior strengthens the relation between ethical codes and enforcement. Codes can also be recognized in a court of law under a provision called judicial notice. This term acknowledges that while a code is not a legal mandate, the court can apply as doctrine of evidence the existence of a particular fact commonly known by persons of average intelligence. In other words, common knowledge can be considered in a legal court case.

Ideally, codes should create a relationship among members of a profession that are similar to the ties in a family, obviating the need for enforcement outside the group. Professionals’ obligations to each other, to patients, and to society should be similar to the strong obligations and emotional feelings that attend belonging to a family, with the behavior of members being monitored by the membership.

The elements of most codes sound very moral in tone, and this is a legacy from the previous centuries. Early codes were rooted in etiquette more than ethics and were concerned that practitioners be gentlemen of a high-toned moral character. Oaths were taken in very solemn circumstances and warned against “giving poisons” and never to do the sick persons “harm or injustice.” During the Renaissance, writers extolled the physicians to adhere to the intent of the oaths bringing benefit to the sick and avoiding harm, influenced greatly by the religious scholars of the day and what was referred to as divine guidance. In one text of the time, a listing of the sins of physicians addressed what was  obviously in violation of expectations of these individuals ranging of abandoning the sick to treating patients while drunk.5 The health care professionals of today can see the principle roots of our current codes in the ills of this era.

Even hundreds of years ago, people understood that there is power and the potential for exploitation when educated professionals are trusted with the health, legal rights or the safety of the country. The clinician of today must have a strong grasp of the ethical responsibilities as individuals who are trusted with the health of others. Health care professionals have a special responsibility to the patients they treat because of their knowledge and the resultant dependency of the patient on that knowledge and subsequent actions.

A code of ethics also is a set of commandments and, as such, has two principle functions.

• First, it provides an enforceable standard of minimally decent conduct for those who fall below that standard.
• Second, it indicates in general terms some of the ethical considerations a professional must consider when deciding on conduct.6

A code of ethics can and does serve as a tool in the function of self- regulation, an important part of professionalism.

The use of professional codes in health care has some limitations. Not every situation can be addressed in an ethical code or fully explained in an accompanying interpretation. Some philosophers have noted that most codes stress the obligations of health care professionals rather than describe the rights of those receiving health care services.6 The current use of a patient’s bill of rights in health care settings is an attempt to address this discrepancy.

Dental Code

The code for dentists is embodied in the Principles of Ethics and Code of Professional Conduct of the American Dental Association  (ADA).7 The code is maintained and updated by the association through its Council of Ethics, Bylaws, and Judicial Affairs. A code of ethics in dentistry has been in place since 1866 when the first code was simply stated in the words “The dentist should be ever ready to respond to the wants of his patients and should fully recognize the obligations involved in the discharge of his duties toward them.”8 The dental code followed medicine’s lead in laying out the primacy of the patient as the fundamental premise.

The introduction to the code begins with the statement that trust is special and critical to the position that dentistry holds within society. The code mentions the profession is granted privileges and that in return the profession will adhere to “high ethical standards of conduct.” The preamble again calls upon dentists to keep patients as their primary goal highlighting that knowledge, skills and competence and traits of character define the professional person.

The ADA Code is divided into three components: principles of ethics, code of professional conduct, and advisory opinions. The principles of ethics component sets out the aspirational goals of the dental profession, which are similar to the aspirational goals for other health care professions. The code is based on the five fundamental principles of autonomy, beneficence, nonmaleficence, justice and veracity, the major premises of the profession.

The portion of the ADA Code that addresses conduct for dentists—the code of professional conduct—delineates conduct that is either required or prohibited. Each section of the code of professional conduct is followed by an advisory opinion. These opinions expand on an issue and often include legal warnings or suggestions for the dentist to seek further information or advice. Guidance is provided in the ADA Code for anyone who believes a member dentist has acted unethically, and the code further explains that censure or suspension can result from a fair hearing on any unethical conduct. The ADA Code, with current official advisory opinions is available at www.ada.org.

Dental Hygiene Code

The first code of ethics for dental hygienists was created at the inception of the American Dental Hygienists’ Association (ADHA) in 1927.9 The Code was developed in three sections and listed the duties of the profession to patients beginning with the statement, “The dental hygienist should be ever ready to respond to the wants of her patrons, and should fully recognize the obligations involved in the discharge of her duties toward them.” The issue of character was addressed with the admonition that “her manner should be firm, yet kind and sympathizing so as to gain the respect and confidence of her patients, and even the simplest case committed to her care should receive that attention which is due to operations performed on living, sensitive tissue.” The second section cautioned the hygienist that patience will be necessary and the importance of endeavoring to educate the public mind. Lastly, the early Code counselled regarding the primacy of the patient with the hygienist being “temperate in all things, keeping both mind and body in the best possible health, that her patients may have the benefit of the clearness of judgment and skill which is their right.”

The wording of the original code reflects the tone and verbiage of the time and the fact that initially only women were dental hygienists. The code has been revised several times over the years, most significantly in 1995 after a review and the incorporation of newer aspects of health care and changes in the profession. Revisions have been undertaken in more recent years. The current version of the code is presented in several sections and encompasses the areas of endeavor in which the dental hygienist functions.10

The four goals or purposes of the code of ethics are listed in the beginning of the code, and these capture the essence of why the code is important to dental hygienists and the public who entrust themselves for care and services. The purposes listed are to:

• Increase professional and ethical consciousness and sense of ethical responsibility.
• Recognize ethical issues and choices, and guide in decision making.
• Establish a standard for professional judgment and conduct.
• Provide a statement of the ethical behavior the public can expect.10

The key concepts, basic beliefs, fundamental principles, and core values are established and explained in the code so that the standards of professional responsibility can be fully understood by professional and public alike.

The dental hygiene code is maintained by the American Dental Hygienists’ Association House of Delegates and is monitored by the executive staff of the organization. The code of ethics that was developed in 1995 is more comprehensive than earlier versions and provides extensive guidance for the dental hygienist working in a variety of health care delivery settings. The most recent revision lays out five fundamental principles and seven core values to guide practice and frame the ethics of the group.

The fundamental principles are:

• Universality – judging an action to be right or wrong by the similar people in the same situation.
• Complementarity – existence of the obligation to justice and human rights. Calls out the needs and values of others in the provision of services.
• Ethics – broad term that aims to promote good and minimize harm, including health promotion.
• Community – acknowledges the bond among individuals, community and society, leading to preserving the global environment.
• Responsibility – accepting our duty to knowing and making ethical choices, including the consequences of actions or failure to act.

The ADA code refers to five fundamental  principles, whereas the ADHA code identifie score values and fundamental principles. The current code lists the core principles embraced and upheld in all health care professions and clearly defines for all the standards of professional responsibility that the profession believes its members should adhere to in the performance of their services. A code of ethics is a reference and a guide. The ADHA Code of Ethics for Dental Hygienists is available in its entirety at www.adha.org.

ADA Principles of Ethics and Code of Professional Conduct.

personnel; personal impairment; bloodborne pathogens; patient abandonment: Personal relationship with patients
3| Beneficence| Community service; government of a profession; research and development; patents and copyrights; abuse and neglect; professional demeanor in the workplace
4| Justice| Patient selection; emergency service; Justifiable criticism; expert testimony; rebates and split fees
5| Veracity| Representation of care1 fees; disclosure of conflict of interest; devices and therapeutic methods; professional announcement; advertising; name of practice; announcement of specialization; general practitioner announcement of credentials

Codes in Dentistry

All professional codes are evolving documents that embody the contract between a particular profession and the public. Both the ADA and the ADHA as well as all health care professional organizations have an agreement to uphold the profession’s code of ethics as a condition of membership. Since dentists and dental hygienists work together both groups should be familiar with each other professional codes and how they exhibit their commitment to the patient.

The approach of each organization is very similar and the application of principles or values in line with other health care professions. Confidentiality in the dental hygiene code is called out separately but is grounded in the principle of autonomy. Societal trust is so important that the dental hygiene code listed it along with the other values and principles.

A side-by-side comparison of the two organizations first codes clearly demonstrates the aspects of duty, obligation and the primacy of the patient over self-interest of the clinician. Other dental groups, such as the American College of Dentists, a professional organization that is by invitation only, was founded in 1920 to elevate the standards of dentistry, encourage continuing education and acknowledge those individuals who provide exceptional contributions and leadership to dentistry and society. The College, through its many publications and programs, stresses excellence, ethics, professionalism and ethical decision-making for members and nonmembers of the greater dental community. The Code of Conduct of the American College of Dentists can be found at acd.org

For students of dentistry and dental hygiene, the code of ethics are vehicles for educating novices about the obligations of the profession, informing them about the basic beliefs and fundamental principles of the group, and providing guidelines regarding the expected behavior of a clinician and practitioner. Each major association, the ADA and ADHA support a student version of its main organization to encourage the ethical and professional development of the student learner.11

Effectiveness of Codes

Does the public consumer of dentistry recognize the presence of codes of ethics?
In 2015, the ADA Council on Ethics, Bylaws and Judicial Affairs (CEBJA) commissioned a consumer survey regarding the ADA Principles of Ethics and Code of Professional Conduct. The results of the survey supports the belief that the ADA Code is noticed, acknowledged, and elevates the reputation of the dentist in the community. According to the survey of 1000 people, nearly 75% of patients reported they are more likely to choose an ADA member dentist knowing that those dentists follow an ethical code.12 This is very reassuring to the organization and its investment in maintaining and promulgating the Code of Ethics among its members. Two in five consumers asked believed that ADA dentists hold themselves to a higher standard than other dentists. Interestingly, patients in the 35-64 age range were more likely to be influenced by the Code when choosing a dentist, while those 18-24 age range were considerably less influenced by the Code. This finding is not surprising as younger individuals seek information and referrals from various types of electronic social media

Dentistry enjoys a strong public reputation and societal trust. Opinion polls usually rank dentists and medical doctors with a very high honesty and ethics rating. The ethical violations that occur are often related to the financial demands of dental practice, and the business side complexities, especially managing employees. Recent research on ethical issues facing practicing dentists placed dental overtreatment at the top of the list, followed by the pressures of third-party insurance payers who influence patient choices and subsequent reimbursement. Another topic of concern was colleagues failing to refer when a clinical case or situation is above the dentist’s skill level. Advertising that is misleading is also as troubling as the presence of colleagues impaired with alcohol or drugs.13 These ethical problems are likely rooted in some aspect of financial practice demand or lack of discernment as to the pull of self-interest.

The goal of the greater profession is to cultivate a culture of ethical excellence. To that end, ethics education is required in dental and dental hygiene schools. The dental and dental hygiene student learns about the ethical and professional responsibilities in numerous formal and informal ways. Ethics and professionalism content is required by the Commission on Dental Accreditation in the predoctoral dental and dental hygiene educational curricula. Currently, the Commission on Dental Accreditation addresses ethics training in Standard 2-21 for the dental standards and 2-19 for the dental hygiene standards. The standard for predoctoral dental students states that “graduates must be competent in the application of the principles of ethical decision making and professional responsibility.” The standard for dental hygiene students indicates that “dental hygienists should understand and practice ethical behavior consistent with the professional code of ethics throughout their educational experience.” Part of that education process is learning and applying the code of ethics. The two main goals of dental education programs in regards to ethics are that students gain the awareness to discern ethical issues and the commitment to act appropriately on a decision when necessary.

Conclusion

Integrity is an ethical stance that leads an individual to adhere to his or her values. An ethical code is a listing of principles, values and aspirations based on desired conduct and born in the traditions of the healing professions. It is more than a set of polite rules or an excuse for promoting self-interest. Codes serve as a touchstone by which all members of a profession can judge the acceptable parameters of behavior and is the basis for self-regulation. This is why being a professional person is a privilege and carries both benefits and responsibilities.

Course Test Preview

To receive Continuing Education credit for this course, you must complete the online test. Please go to: www.dentalcare.com/en-us/ce- courses/ce528/test

1. Ethical codes lay out the goals and aspirations of a group and address areas of ___.
   A. ideas and obligations
   B. integrity, dedication and principles of behavior
   C. scope of practice and rules
   D. normative principles, rules and harm avoidance

2. A virtue is defined as a ___.
   A. character trait
   B. behavior
   C. type of modeling
   D. type of beneficence

3. Educational institutions seek to prepare students for working in the health care professions by ___?
   A. being good patients
   B. teaching about the codes of the professions
   C. careful selection of textbooks
   D. teaching and learning with others

4. A bad clinical outcome from medical or dental treatment does not always indicate unethical conduct. The responsibility of the dental professional when unethical conduct is observed is to:
   A. intervene in a substantive way.
   B. seek consultation.
   C. report the conduct to state or regional board.
   D. report the conduct to the local association.

5. A code of ethics is a promise to society to ___.
   A. uphold the legal statutes of the federal government
   B. uphold the standards and values of the profession
   C. guide all clinical and professional care
   D. guide the selection of future professionals

6. Judicial notice is a term that means a court of law ___.
   A. can apply as doctrine of evidence the existence of a particular fact
   B. cannot apply any evidence not based in fact
   C. can use any facts that are found in a patient record
   D. cannot apply as a legal or ethical mandate

7. Problems in the 15th century with physicians who revealed the secrets of patients is known today as ___.
   A. autonomy
   B. beneficence
   C. justice
   D. confidentiality
   E. veracity

8. Problems in the 15th century with physicians who treated patients while drunk is known today as ___.
   A. autonomy
   B. beneficence
   C. justice
   D. nonmaleficence
   E. veracity

9. The first dental code has been in place since ___.
   A. 1866
   B. 1899
   C. 1900
   D. 1927

10. The primary goal of the dental code of ethics as stated in the preamble is to ___.
    A. always maintain justice
    B. keep the legal mandates
    C. keep the patient as primary
    D. always consider beneficence first

11. The first dental hygiene code was created in ___.
    A. 1866
    B. 1899
    C. 1900
    D. 1927

12. The values utilized in the dental hygiene code of ethics are ___.
    A. autonomy, beneficence, justice, nonmaleficence and veracity
    B. individual autonomy, beneficence, justice, nonmaleficence, veracity, confidentiality and societal trust
    C. beneficence, paternalism, principlism, distributive justice and professional authority
    D. beneficence, justice, caring, veracity, principlism, autonomy and nonmaleficence

13. The term complementarity can be defined as ___.
    A. approachable
    B. cultural competence
    C. unrespectful
    D. obligation

14. What percentage of patients in a 2015 survey by the American Dental Association stated that they were likely to choose an ADA member dentist knowing that those dentists follow an ethical code?
    A. 45
    B. 50
    C. 60
    D. 75

15. The main goal of ethics education in dental education programs “is to _____.”
    A. memorize the code of ethics
    B. learn about the Hippocratic traditions
    C. learn ethical decision-making
    D. apply ethical virtues

References

1. Edge RS, Groves JR. Ethics of health care: a guide for clinical practice. Clifton Park, NY. Thomson Delmar Learning; 2006. p 84.
2. Beemsterboer PL. Ethics and Law in Dental Hygiene, 3rd edition. St. Louis, MO. Elsevier; 2017.
3. Kenny NP. Codes and character: the pillars of professional ethics. J Am Coll Dent. 1998 Fall;65(3):5-8.
4. Beauchamp TL, Childress J. Principles of Biomedical Ethics, 7th edition. New York, NY. Oxford University Press; 2013.
5. Jonsen AR. The sins of specialists. J Hist Dent. 2007 Winter;55(3):113-8; discussion 171-85.
6. Benjamin M, Curtis J. Ethics in nursing, 2nd edition. New York, NY. Oxford University Press; 1986. p 6.
7. American Dental Association. Principles of Ethics and Code of Professional Conduct. Accessed March 9, 2023.
8. Code of Dental Ethics (1866). J Am Coll Dent. 2015 Fall;82(4):18-9.
9. Steel PF. Dimensions of dental hygiene, 3rd edition. Philadelphia, PA. Lea & Febiger; 1982. p 474.
10. American Dental Hygienists’ Association. Code of Ethics for Dental Hygienists. Accessed March 9, 2023.
11. Beemsterboer PL, Stewart JCB. Codes of Ethics in Our Professional Heritage. Oregon Dental Association Membership Matters. June/July 2016.
12. Burger D. Code of Ethics spurs public’s decision in choosing dentists, survey says. ADA News. 2015 Jul 15. Accessed May 31, 2020
13. Ozar DT, Patthoff D. Dental Ethics at Chairside: Professional obligations and practical applications, 3rd ed. Washington DC GeorgeTown University Press. 2018

Additional Resources

• No Additional Resources Available

About the Author

Phyllis Beemsterboer, RDH, MS, EdD, FACD

Dr. Phyllis L. Beemsterboer is Professor Emeritus in the Schools of Dentistry and Medicine and former Associate Dean for Academic Affairs in the School of Dentistry at Oregon Health & Science University in Portland, Oregon. She is an associate director in the Center for Ethics in Health Care at OHSU. Her research interest is in bioethics education and she is past president of the American Society for Dental Ethics. She was a Gies Fellow at the American Dental Education Association in 1997 and completed the Executive Leadership in Academic Medicine Program (ELAM) in 1998.

Dr. Beemsterboer’s past academic activities include journal publications in bioethics, occlusion and temporomandibular research, service on numerous dental education review boards, academic consulting and the author of two dental hygiene textbooks. She has extensive experience in accreditation, assessment and evaluation. Dr. Beemsterboer was elected to the American College of Dentists as an honorary member in 2010 and received a Presidential Citation from the American Dental Education Association in 2013.

Email: beemster@ohsu.edu

References

• ACD | American College of Dentists
• Home | American Dental Association
• Code on Nomenclature (CDT) Code | American Dental Association
• Home - ADHA
• Ethics in Dentistry: Part II - Codes of Ethics - Dentalcare Course | Dentalcare
• Ethics in Dentistry: Part II - Codes of Ethics - Dentalcare Course | Dentalcare
• American College of Dentists
• Ethics in Dentistry: Part I - Principles and Values - Dentalcare Course | Dentalcare
• Ethics in Dentistry: Part II - Codes of Ethics - Dentalcare Course | Dentalcare
• Ethics in Dentistry: Part III – Ethical Decision-making - Dentalcare Course | Dentalcare

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