versão On-line ISSN 0375-1562
versão impressa ISSN 0011-8516
S. Afr. dent. j. vol.69 no.8 Johannesburg 2014
S NaidooI; J du Toit
IBDS (Lon), LDS.RCS (Eng), MDPH (Lon), DDPH.RCS (Eng), MChD (Comm Dent), PhD (US), PG Dipl Int Research Ethics (UCT), DSc (UWC). Senior Professor and Principal Specialist, Faculty of Dentistry, University of the Western Cape
While dentistry remains firstly a health profession, it is naïve and unrealistic not to realise that business considerations and financial compensation for services rendered play an important role in achieving a successful private practice. A fundamental principle of professional ethics in healthcare is that serving a patient's best interests should always take precedence over any consideration of profit or personal gain. George Merck, the founder of Merck Pharmaceuticals said "Medicine is for the patient, not for the profits. The profits follow" ...the same can be said for dentistry. However, since dentists are in a position to gain financially from their professional recommendations, there is a risk of their having a conflict of interest, whether actual or perceived.
Patients have a right to know, in advance of treatment, how much their dental treatment is likely to cost and if fees might increase for any reason. In addition, the patient must be informed should the original treatment plan need to be altered in any way as treatment proceeds. Autonomy literally means self-rule. It refers to the right of every individual to make decisions for him/herself. In health care this means allowing the patient to make the final decision regarding his/her treatment, after providing all the necessary and relevant information. Involving the patient actively in treatment plan decisions is fundamental part of the informed consent process. If there are alternative treatment options, the patient should be given a fair and balanced explanation of what they are, and how they compare, including the relative costs of each option.1
According to the National Health Act of No 61 of 2003, Chapter 2 Section 6, the following information must be given to the patient (User of Health Care Services)2:
- Range of diagnostic procedures and treatment options available;
- Benefits, risks, costs and consequences associated with each option;
- User's right to refuse care and explain implications, risks and obligations of such refusal and
- Furthermore, this information must be provided in a language that the patient understands and in a manner that takes into account the patient's literacy level.
Professional decision-making usually involves many factors. However, the question of financial gain must never be a consideration when making professional recommendations. A patient's ability to pay for services may be a consideration when making recommendations, and by always considering the patient's best interests, the profession of dentistry can ethically exist within a business structure. But never make assumptions regarding the patient's ability or willingness to pay fees. Offering only the treatment that you think the patient can afford, or compromising on treatment because you think the patient can't or won't pay for a more expensive option invites problems.3 Nowadays, many patients are not accepting treatment plans, despite wanting or needing treatment, because they cannot afford the options or because the medical aid companies have reduced dental benefits.
With proper education patients who can afford treatment can be motivated to accept it and stimulate behaviour change. Not educating the patient results only in requests from the patient for minimal, urgent treatment. In-depth patient education on the other hand may lead to acceptance of at least a part of the proposed treatment plan. While most dentists will be able to easily devise the best treatment plan for their patients - the challenge is getting the patient to accept the recommendations. The "best" treatment plan is often not the most expensive plan. The risks, benefits, costs and effectiveness of alternative techniques must be considered and this decision-making process is called 'justification' and is both an ethical and legal requirement.4 Dentistry presents unique challenges to the justification process in treatment planning. The patient's history and risk of disease will determine the treatment which may be required. As mentioned above, autonomy refers to the right of every individual to make decisions for him/herselfl and therefore one expects that after having been provided with all the necessary and relevant information the patient can make the final decision regarding his/her treatment options. But how can we ensure that patients make the best and most appropriate decisions about their treatment plan?
Patients need to be educated about the oral condition or problem that they present with. This exercise if often timeconsuming as it often requires a systematic data collection to make a comprehensive diagnosis. Good patient education is critical for optimum acceptance of treatment plans. In some cases, patients may not understand the consequences of their requests or have unrealistic expectations of the proposed outcomes. In such instances, additional patient education or explanation to a competent surrogate may be required. The patient must be permitted to ask any questions and the correct responses will result in their further education. Estimates of the costs of the various treatment options must be discussed and if costs are too high, payment options or different treatment plan options should be considered. Fees should be consistent and fair to all parties Dentists should not vary fees based solely on the patient's financial resources, including medical insurance plans. Payment options should be disclosed to patients and agreed upon prior to any services being performed. Financial arrangements for treatment are part of informed consent discussions, The aim of patient education is to have the patient accept the most appropriate treatment plan.
It is a complex situation for health care providers including the dental profession to strike a balance between a caring, supportive and patient-centred approach to care, and the need to make a living and to run a profitable business in order to achieve this. Striving to act ethically and professionally at all times will assist in finding this elusive balance, and ultimately it will be more rewarding and professionally satisfying3 The dentist has an ethical obligation to inform responsible parties about treatment choices, costs, possible complications, and expected outcomes when determining what is in the patient's best interests. The "best interest" of patients means that professional decisions of proposed investigations and any reasonable alternatives proposed by the dentist must consider patients' values and personal preferences. This must be done in a manner that allows the patient to become involved and requires careful communication with patients. Listening is of paramount importance.1
In some instances, patient desires may conflict with professional recommendations and one is faced with a real dilemma in respecting the autonomy of the patient. Patients must be informed of alternative treatments, advantages and disadvantages of each, costs of each, expected outcomes and possible complications. Together, the risks, benefits, and burdens can be balanced. It is only after such consideration that the "best interests" of patients can be assured. Dentists must present honest, thorough treatment plans and charge moderate, reasonable fees. Such activities will increase treatment plan acceptability, motivate new patients to stay and help ensure a practice's financial viability and success1
1. Mcodley K, Naicloo S, Ethics for the Dental Team, Van Schaik Publishers, Pretoria, 2010. [ Links ]
2. South African Parliament. National Health Act of No 61 of 2003, Chapter 2 Section 6, Pretoria. [ Links ]
3. Dental Protection Limited. Ethics, values, and the law. Module 2: Ethics, and Business, 2009 [ Links ]
4. Horner K. Radiographic selection criteria: new guidelines, old challenges, British Dental Journal 2013; 214: 201-3. [ Links ]
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