Ethical Decision Making

Dental hygienists face ethical questions and dilemmas throughout professional practice. These problems arise when the clinician is caught between competing obligations and has to weigh two or more options to resolve the situation. In “Facing Ethical Dilemmas” (published in Dimensions’ December 2009 issue and available at www.dimensionsofdentalhygiene.com), the role of ethical principles was examined in healthcare and their application to the practice of dental hygiene.¹

Ethical decision-making models provide a suggested mechanism or tool for critical thinking and resolution of ethical dilemmas. Dental schools and dental hygiene schools now commonly provide students the opportunities to develop the analytical skills needed to assess and resolve ethical dilemmas. The teaching of ethics has been acknowledged as an essential part of the education of the dental health care professional since 1989, when the American Dental Education Association (ADEA) established guidelines that stated curriculum should provide opportunities for refining skills of ethical analysis so students are able to apply ethical principles to new and emerging problems in the profession. The goal for these curricula was to develop a commitment by the students to the principles and ideals that are the basis of the profession’s contract with society.

ETHICAL DECISION-MAKING MODEL

An ethical decision-making model is a tool that can be used by a dental hygienist or any other health care provider to help think through an ethical dilemma and arrive at an ethical decision. A number of models are presented in ethics literature, all of which are somewhat similar in design and content.² The goal of each is to provide a framework for making the best decision in a particular situation. Most models use principle-based reasoning, an approach derived from the work of philosophers Beauchamp and Childress.³

The model provided here is a simple, six-step approach derived from the decision-making literature as interpreted by Atchison and Beemsterboer and used in the early 1990s with dental and dental hygiene students in a combined ethics course.⁴ It is a reasoned approach based on theory and principle. The model has been diagrammed as a circle to emphasize the use of past information and experiences in current and future decision making (Figure 1).

The decision-making process is dynamic and evolves as additional information comes into play. Dental hygienists are confronted with numerous questions that require them to factor in the code of ethics and their own values and beliefs before arriving at a decision. The evaluation process involved in resolving an ethical dilemma is not unlike that which occurs when practitioners are faced with a clinical or scientific problem: careful attention to and systematic analysis of the evidence, facts, and details will help health care providers reach appropriate decisions.

Applying the decision-making model gives dental hygienists a tool to use throughout their professional lives. Writing out the thinking behind each step enables the clinician to review the document during the ethical decision-making process.

FIGURE 2. PRINCIPLES OF ETHICAL DECISION MAKING

1. Principle of Autonomy Respect for Life Respect for People Paternalism Confidentiality Informed Consent
2. Principle of Beneficence
3. Principle of Nonmaleficence
4. Principle of Veracity Truthtelling Honesty
5. Principle of Justice Rightness Equity, Fairness

SIX-STEP MODEL

1. Identify the Ethical Dilemma or Problem. This is the first and most critical step in the process. Many situations are simply never perceived as ethical problems or dilemmas. Once a problem has been recognized, the decision maker must clearly and succinctly state the ethical question, but only after considering all pertinent aspects of the problem. If the ethical question does not place principles in conflict, it is a simple matter of right and wrong and no process of ethical decision making is required. Step two is not necessary if a clear determination of right or wrong has been made.

2. Collect Information. The decision maker must gather information as a basis for an informed decision. This may include facts about the situation as it developed, which may come from more than one source. Information regarding the values of the parties involved, including those of the patient and the healthcare provider, is needed. This step often takes time, since the information may not be readily available.

3. State the Options. After gathering all the necessary information, the third step involves brainstorming to identify as many alternatives (or options) as possible. Often the best decision is not the first one that comes to mind. There is also a tendency to think that a question has only one answer. This step forces us to view the situation from all angles in order to identify what other people might see as alternative answers to the problem. An enlightened and open mind is a prerequisite.

4. Apply Ethical Principles to the Options. The next step is to view the situation with a focus on ethical principles (autonomy, beneficence, nonmaleficence, and justice) and ethical values and concepts (paternalism, confidentiality, and informed consent), as one or more may be involved in reaching an ethical decision (Figure 2). State how each alternative will affect the ethical principle or rule by developing a list of pros and cons (Figure 3 worksheet). In the “pro” column, show alternatives that protect or hold inviolate each principle or value. Under “cons,” state how an alternative could violate the principle or value. After conducting this analysis for each option, it becomes apparent which ethical principles are in conflict in any given situation. Refer to the American Dental Hygienists’ Association Code of Ethics for Dental Hygienists for guidance.

5. Make the Decision. When each alternative has been clearly outlined in terms of pros and cons, you have a reasonable framework to reference in making a decision. Each option must then be considered in turn, with attention to how many pros and cons would attend each decision. The seriousness of the cons must then be weighed by the clinician, remembering that, as a professional, he or she is obliged to put the patient’s interests first. Simply by examining the options in a careful manner, the best solution to an ethical dilemma frequently emerges. Before implementing the decision, the practitioner should replay each principle against the decision to determine if the decision holds up to this evaluation.

6. Implement the Decision. The final step involves acting on the decision. Unfortunately, appropriate decisions are sometimes not implemented. Taking no action represents tacit approval of a situation.

ETHICAL DILEMMAS FOR DENTAL HYGIENISTS

A dental hygienist may be faced with a variety of ethical issues and moral dilemmas. Commonly encountered issues include substandard care, patient overtreatment, confidentiality breaches, fraud, suspected abuse, sexual harassment, scope of practice challenges, and dealing with impaired professionals.⁴

Dentistry usually is performed in solo or small group practices where formal groups, such as ethics committees or standard review boards, provide little, if any, institutional oversight. A dentist usually employs dental hygienists, and this arrangement can place dental hygienists in difficult situations when inappropriate care or unethical practices are observed, especially when the dentist-employer is involved. If the dental hygienist advocates the good of the patient in such situations, his or her employment may be in jeopardy, and this could cause moral distress. Conversely, if the dental hygienist remains silent, professionalism is compromised and no one speaks for the interests of the patient.

A conflict or dilemma can be intensified when a subordinate observes an unethical action performed by an individual in a position of power.⁵ Studies from the nursing literature have reported such situations having a negative impact on the health care environment and leading to burnout and departure from the profession.

Additional types of dilemmas and problems can and will arise for dental hygienists and dentists, as advances in technology and changes in delivery systems in dentistry will further alter the scope and depth of ethical challenges.⁷ Increasingly, dental hygienists are finding employment in areas besides private practice, such as research, public health and corporate fields); these work environments may pose different ethical dilemmas for these individuals.

Many healthcare workers find that talking to trusted colleagues and peers about ethical dilemmas and work problems is both beneficial and comforting. The ethical decision-making process presented here can be applied by small groups, and is equally effective for students and experienced practitioners.

Ethical choices and dilemmas will occur throughout the professional life of any healthcare worker. Fortunately, this six-step model can provide structure and guide dental clinicians when faced with ethical dilemmas and tough decisions.

REFERENCES

1. Beemsterboer PL. Facing ethical dilemmas. DImensions of Dental Hygiene . 2009;7(12):44-47
2. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 4th ed. New York: McGraw-Hill; 1998.
3. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press; 2001.
4. Beemsterboer PL. Ethics and Law in Dental Hygiene . 2nd ed. St. Louis: Saunders Elsevier; 2010.
5. Ozar DT, Sokol DJ. Dental Ethics at Chairside: Professional Principles and Practical Application. 2nd ed. Washington, DC; Georgetown Press; 2002.
6. Redman B, Fry ST. Nurses’ Ethical Conflicts: What is really known about them? Nurs Ethics. 2000;7:360.
7. Rule JT, Veatch RM. Ethical Questions in Dentistry. 2nd ed. Hanover Park, Ill: Quintessence Publishing Inc; 2004.

From Dimensions of Dental Hygiene. June 2010; 8(6): 78-81.