ETHICS IN ESTHETIC DENTISTRY Arlinda Luzi Luzi

ETHICS:
A discipline dealing primarily with moral duty, conduct, and judgment.

These are standards of behavior which we choose to accept for ourselves –

not those imposed by some other authority.
HIPPOCRATES, THE OATH
I will follow that system or regimen
which according to my ability and
judgment I consider for the benefit of
my patient and abstain from
whatever is deleterious and
mischievous.
 BASIC CONCEPTS AND PROBLEMS
1. Morality and Ethical Theory:
Morality: A social institution, concerned with social practices
defining right and wrong. It’s composed of a set of standards
which is pervasively acknowledged by a culture or a people.

Ethical Theory: an activity in which one engages in reflection on

the nature and justification of right actions.
2. Morality and prudence

Prudence: Self interest (don’t touch the stove, brush your teeth—
not moral rules)

Morality: Is not reducible to prudence. Prudence is self-interest

whereas morality extends to others. Prudence and morality may
coincide, but that which is prudent may not be moral, and that
which is moral may not be prudent.
3. The Rule of Conscience:

Let your conscience be your guide. Certainly, conscience is not

the end all and be all of morality. People’s consciences will tell
them very different things in very similar circumstances. Yet,
should you ever do what your conscience tells you is the wrong
thing? Ethicists disagree.
4. The Common Morality:
Those of us who are committed to morality share a set of norms, even
though these norms may be very general. We all agree at least that
any of the norms that we hold apply to all people, or to all who are
members of the moral community. We cannot arbitrarily exclude any
of those we may not like, or who may not like us. The common morality
applies to everyone.

The basics of common morality are best expressed, perhaps, in the

three basic factors of morals: the good, the right, and the virtuous.
The first factor contemplates ends or outcomes; the second with duties
and obligations, the third with character formation.
5. Moral Dilemmas and Solving Moral Disagreements:

Genuine moral dilemmas are real and difficult. The Tarasoff

case (p. 45-49) is a good example. It’s a moral dilemma
because there are very good reasons for mutually exclusive
alternatives. If one set of reasons is acted upon, events will
result that are desirable in some respects but undesirable in
others.
 HEALTH CARE
“health care”: provision of assistance to persons in need of care, cure,
education, prevention, or help related to trauma, illness, disability or
dysfunction by other persons knowledgeable and skillful in providing such
assistance.
Journal of Medicine and Philosophy, 1999, Vol. 24, No. 3, pp. 243-266 (Pellegrino)
 DENTISTRY

Dentistry as a profession is
“based in service, in preventing
and treating disease, and in
restoring health.”
Simonsen, 2007
COSMETIC DENTISTRY
 WHAT IS BIOETHICS?
Bioethics involves critical reflection on moral/ethical problems faced in
health care settings toward:
 deciding what we should do
 explaining why we should do it and
 describing how we should do it
 (Dr Barb Secker)
 CHEATING
Cheating is Endemic in today´s world.
The most serious instances of Cheating in the healthcare world have
involved the fudging of data, or their outright invention, in some of our
scientific publications.
“Big Pharma” has paid a radio host for giving their drug marketing lectures
 CHEATING
Andrew Wakefield in an article published in the prestigious Lancet claimed
a possible link between the measles, mumps and rubella vaccine and
autism. This fact was not true and has been proved by other authors, for this
wakefield was found guilty of serious professional misconduct.
 CHEATING
In 2009 the world´s largest drug company Pfizer, plead guilty in court to
criminal charges that it broke the law in marketing the drug bextra.
 JONSUDBØ
• born on May 3, 1961
• Norwegian dentist / physician / oral surgeon
• renowned researcher in the field of oncology
– articles in NEJM, Journal of Clinical Oncology (IF=18.4), The
Lancet, Journal of Pathology, etc.
• associate professor @ University of Oslo
– until 2006
• consultant oncologist @ Radium Hospital
– until 2006
 THEPAPER

Non-steroidal anti-inflammatory drugs and the risk of oral

cancer: a nested case-controlstudy
JSudbø,JJLee,SM Lippman, JMork, SSagen,N Flatner, ARistimäki, ASudbø,LMao, XZhou, WKildal, JFEvensen,AReith, AJDannenberg
 RESULTS
• Useof NSAIDs&paracetamol

– reducedriskof oralcancer
• NSAIDs reducedrisk evenfor heavysmokers(>40packyears)

– noassociationwith overallsurvival

– someNSAIDs increasedriskfor cardiovascular-‐disease-‐relateddeath

 „BADLUCK“
Christmas 2005

• Camilla Stoltenberg (head of Norwegian Institute of Public Health

AND sister of Prime Minister of Norway)
– found it suspicious that

the database -‐ mentioned in the article -‐ was supposed to open at the

beginning of 2006
 „BADLUCK“
• C.S. started „digging“ and found out that

250of the patients had birthday on

the sameday

Report in“ “
 THEFRAUD
Stein Vaaler, director of strategy @ Radium Hospital:

(...)“He faked everything: names, diagnosis, gender, weight, age,drug use.

There is no real data whatsever, just figures he madeup himself. Every
patient in this paper is afake“ (...)
THEFRAUD
30June of 2006 report of thecommission:

15 of his articles werefraduelent, incl. his

doctoral dissertation
 CONSEQUENSES
• Retraction of several fraudulentarticles
 CONSEQUENSES
• Resigned from all university-‐basedpositions in 2006
• Revocation of the license to practice medicine and
dentistry 2006
• Revocation of the doctoral thesis in 2006
 TRADITIONAL PRINCIPLISM
Patient Autonomy
Beneficence
Non-maleficence
Justice
Veracity
 AUTONOMY
The right of a competent person to make informed decisions regarding
his/her health options.

“Understanding and respecting patients’ rights to make informed decisions

based on personal values and beliefs.”
RCDS Code of Ethics
TRADITIONAL VIEW OF AUTONOMY
 Autonomy
 Individualism
 Contractual nature of helping
relationships
 Right to make an ill- advised
decision
 People have experience &
skills in exercising autonomy
 There are choices through
which to exercise autonomy
AUTONOMY
The dentist has a duty to respect the patient´s right to self-determination
and confidentiality.
 Multiple option of treatments
 Open and honest discussion
AUTONOMY
Informed consent Induced consent
LAW, AUTHORITY, AND
AUTONOMY:
Liberty limiting principles:

a. The Harm Principle: A person’s liberty is justifiably restricted only to prevent harm to others caused
by that person.

b. The Principle of Paternalism: A person’s liberty is justifiably restricted to prevent harm to self
caused by that person.

c. The Principle of Legal Moralism: A person’s liberty is justifiably restricted to prevent that person’s
immoral behavior.

d. The Offense Principle: A person’s liberty is justifiably restricted to prevent offense to others by that
person.
 BENEFICENCE
“ Every act and every inquiry, and similarly every action and pursuit is
thought to aim at some good and for this reason the good has rightly
been declared to be that which all things aim.”
Aristotle, Nicomachean Ethics, 1094a 1-3

“Maximizing benefits and minimizing harm for the welfare of the patient”
Code of Ethics
 BENEFICIENCE
You can choose an esthetic treatment that will obtain a short-term
improvement in appearance but if the result is significant reduction of tooth
structure that later requires endodontic care and/or additional restorative
treatment the patient has not been well served.
 NON MALEFICENCE
BLAIR HENRY

Do no harm or allow harm to happen

 What are the provider’s biases?
 What can be done to protect the patient?
 Would the action cause harm or make the patient worse?
 What negative outcomes are possible with and without action?
 NON MALEFICENCE
The dentist has to recognize the scope of his/her own skills and knowledge
and seek for advice or referring the patient to a specialist or another
practitioner if the problem lies outside of his/her area of expertise.
 JUSTICE
Balancing the rights and well-being of the individual with the rights and
well-being of others
Broader societal considerations in distribution of scarce health resources
Laws
Health Policy
Public health
JUST ACCESS TO COMPREHENSIVE DENTAL
CARE
 VERACITY
Truthfulness is applied to any communication between dentist and patient.
Violations are most common in advertising and can be found en masse on
dentists´websites.
CATEGORICAL IMPERATIVE

“Act so that you treat humanity, whether

in your own person or that of another,
always as an end and never simply as a
means.”

Immanuel Kant
German Philosopher
1724-1804
 PATIENTS: MEANS OR ENDS ?
As a profession, dentists serve the end of the well-being of their patients.
To place one’s own interest above the welfare of a patient is to treat a patient
as means to the dentist’s ends. The patient becomes an ‘object’ to be used by the
dentist in achieving personal goals. This is reification; treating another as an
object--dehumaning.
“Always treat others as ends in themselves, never as a means to one’s own ends.”
Immanuel Kant’s Moral Imperative.
Clearly we derive financial gain from our life’s work, but it is derivative; a by-
product of us fulfilling our promise to our patients as professionals that they can
always trust us to do what is in their best interest.
 PATIENTS: MEANS OR ENDS
Dentistry as a business sees the oral health of patients, not as ends in
themselves, but merely means to the dentist’s personal ends.
Dentistry as a business serves the end of personal profit for the dentist.
Understanding dentistry primarily as a business places dentistry in the
marketplace where oral health care becomes a commodity produced
and sold for a profit.
The business of selling cures undermines the classical professional
model—a model rooted in a tradition of caring.
 “Health care is not a commodity, and treating as such is deleterious to
the ethics of patient care. Health is a human good that a good society
has an obligation to protect from the market ethos.”

Edmund Pellegrino, M.D.

Distinguished Bioethicist
Georgetown University
WHY ETHICS MATTER?
 EVOLUTION OF GOALS/VALUES

We are faced with a balancing act between fidelity to the moral wisdom of
the past and responsive adaptation to the circumstances of the present.
Miller & Brody, 2001
JUST BECAUSE WE CAN DO IT, OUGHT WE DO IT?
October 20, 2009|Kimi Yoshino
The Beverly Hills fertility doctor who treated octuplets mom Nadya Suleman
has been expelled from the American Society of Reproductive Medicine for
a "pattern of behavior" detrimental to the industry, a spokesman for the
association confirmed Monday. Los Angeles Times
WHAT IS THE POTENTIAL FOR CONFLICT OF
INTERESTS?
Dentist as health practitioner
and…
Dentist as business
manager/entrepreneur and…
Dentist as purveyor of beauty
enhancement procedures
OVERTREATMENT OR GOOD
CLINICAL/ESTHETIC OUTCOME?
WHAT IS HEALTHY? WHAT IS NORMAL?
DOES IT MATTER?
UK Chic Hollywood update
 WHAT IS NORMAL? WHAT IS HEALTHY?
DOES IT MATTER?
Some ethicists, philosophers and policy makers are urging a reorientation of
the physician’s beneficence from an exclusive focus on the good of
individual patients to a focus on societal good.
Pellegrino, 2001
 ARE DENTAL SERVICES A COMMODITY?
Is health care (dental care) sufficiently different from pantyhose, ocean-front
condominiums, or television sets to set it apart from other consumer goods?
Journal of Medicine and Philosophy, 1999, Vol. 24, No. 3, pp. 243-266 (Pellegrino)
ARE DENTAL SERVICES A COMMODITY?
 CULTURE, CONTEXT & COMMODITIES
Commodities may be used in the process of providing care, but the totality
of health care itself is not a commodity.
Journal of Medicine and Philosophy, 1999, Vol. 24, No. 3, pp. 243-266 (Pellegrino)
STICKING WITH CORE VALUES
 PROFESSIONALISM, STANDARDS &
ACCOUNTABILITIES
 Maintaining core values of dentistry:
Health promotion- disease prevention
 Critical analysis of market driven incentives to offer cosmetic procedures
 Where is the ethical tipping point between professionalism and overtreatment?
 Promoting ethics in daily practice
 Joint accountabilities: ethical implications regarding cosmetic enhancement procedures
 KEY QUESTIONS FOR ETHICAL PRACTICE

What are my motives in offering this cosmetic option to my

patient? Are these motives consistent with primary clinical
and ethical duties to promote health and prevent disease?
Am I qualified and proficient (training and experience) to
offer this cosmetic procedure?
Have I sufficiently addressed any COI in offering these
treatments to my patient?
KEY QUESTIONS FOR ETHICAL PRACTICE
What personal/cultural bias on gender, beauty etc informs the way I am assessing my
patient’s oral health and/or appearance?
Has the information shared with the patient included short-term, long-term and perhaps
yet to be discovered risks?
Is the level of risk ethically acceptable/defensible given the likely health benefits to the
patient?
OVER-TREATMENT
CLINICAL CASES FOR DISCUSSION
CLINICAL CASES FOR DISCUSSION
CLINICAL CASES FOR DISCUSSION
CLINICAL CASES FOR DISCUSSION
CLINICAL CASES FOR DISCUSSION
CLINICAL CASES FOR DISCUSSION
CLINICAL CASES FOR DISCUSSION
CLINICAL CASES FOR DISCUSSION
CLINICAL CASES FOR DISCUSSION