On-line version ISSN 0375-1562
S. Afr. dent. j. vol.70 n.8 Johannesburg 2015
BDS (Lon), LDS.RCS (Eng), MDPH (Lon), DDPH.RCS (Eng), MChD (Comm Dent), PhD (US), PG Dip! Int Research Ethics (UCT), DSc (UWC). Senior Professor and Principal Specialist, Faculty of Dentistry, University of the western Cape, department of Community dentistry, Private Bag X1, ïygerberg 7505. e-mail: firstname.lastname@example.org
Dental professionals encounter a number of challenging ethical and legal dilemmas on a daily basis that often arise due to conflicts between the ethical principles of autonomy, non-maleficence (do no harm), beneficence (do good), justice, veracity, and fidelity. The application of ethical principles has always been important during any patient encounter, and previously a health professional's obligation was focussed on doing good and avoiding harm rather than giving in to the patient's requests. Today a patient-centred holistic approach and respect for patient autonomy is a more apparent in health care.
In the practice of dentistry, extractions are indicated for a variety of reasons. Third molar teeth are frequently extracted due to impaction, other teeth are extracted due to caries, periodontal disease, trauma, and for prosthetic and orthodontic reasons. As with all our treatment, the role of the dentist will be to inform the patient of the diagnosis, treatment options, risks and benefits, among other factors, and the patient will then weigh up the alternatives and has the option to agree to the treatment proposed. However, this is not always the case and patients may request the removal of teeth, despite the fact that there is no indication for that approach. In these situations, it is important to distinguish whether an irrational request is made by a patient with the capacity to consent and or by a patient without the capacity to consent. The patient's request could be on account of fear, or a mental disorder such as post traumatic stress disorder, a somatoform pain disorder or a disorder of body image perception.1 Although patient's aesthetic goals are important in treatment planning, a dentist has an ethical responsibility to educate them regarding realistic goals and appropriate treatment options. The dentist is then faced with the question of whether the patient is mentally competent to make the decision. In the case of a request for tooth removal made on a psychopathologic basis, a dentist has to refuse to carry out such treatment, but should make an effort to help or guide the patient to seek other care.1
When assessing a request for extraction three concepts are critical - that of informed consent, 'best interest' and the standard of care. When obtaining informed consent for treatment, practitioners must consider both the legal competence and decision-making capacity of the patient. If decision-making is impaired, input should be solicited from others to arrive at treatment decisions in keeping with the patient's values concerning dental care.2 When a patient is able to make his/her own decisions, respect for autonomy is dominant. However, where incompetent patients or young children are concerned, health professionals need to act in the best interests of patient. Respecting the patient's irrational request for extractions (autonomy) conflicts with the principle that it is not in their best interest (beneficence). Patient autonomy in itself is not a rationale for treatment and does not give the patient the right to choose inappropriate treatment.
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 Service)3:
- Range of diagnostic procedures and treatment options available
- Benefits, risks, costs and consequences associated with each option
- User's right to refuse care, in which case the dentist should explain the implications, risks and obligations of such refusal
- 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.
Practitioners must work on the presumption that every adult has the capacity to decide on what treatment they want, unless it is shown that they cannot understand information which has been presented in a clear way. If a patient's choice appears irrational, or does not accord with the practitioner's view of what is in the patient's best interests, this is not evidence in itself that the patient lacks competence. In such circumstances it may be appropriate to review with the patient whether all reasonable steps have been taken to identify and meet their information needs.4
A competent patient is usually able to make a choice based on an understanding of the information given to him/her, an appreciation of the diagnosis, and procedure and its consequences, and will be able to reason and weigh up the proposed treatment options. There are a number of questions to consider when assessing the capacity of patients: Can the person understand the information being provided? Can the person assimilate the information?
Can the person make a decision? Some patients may also present with partial or temporary incapacity and issues like maturity, complexity of the diagnosis, illness, injury, alcohol and drug use may all have an impact on a person's ability to make decisions.5 A person who lacks full capacity may be able to make a rational decision with regard to simple treatment options, but not to more complex reasoning. Where patients have difficulty retaining information, or are only intermittently competent to make a decision, health care practitioners should provide any assistance which may be needed to ensure an informed decision is reached by the patient.4
The health care worker is required to take all reasonable steps to obtain the user's informed consent. However, in situations where patients lack competence to consent, surrogate decision makers must be consulted to represent the 'best interests' of the patient. This principle is often applied in situations of special need and where people do not have capacity to take decisions for themselves. This premise then invites the question, 'Who determines what is in the best interest and what does one do when a conflict arises between various parties with an interest in the welfare of the patient?' Parents are usually regarded as acting in the best interests of their children. But where adults are concerned, practitioners may have an ethical dilemma in deciding what to do when an adult patient is incapable of making a decision for him/herself. What is in the best interests of the patient? Whose moral codes are used to determine this?5
The National Health Act of No 61 of 2003, Chapter 2 Section 7 (Consent of User)3 makes provision for certain persons to consent on behalf of mentally incompetent patients to an operation or medical treatment where such patients are unable to give the necessary consent and have not mandated - while still mentally competent-somebody else in writing to give consent on their behalf. The Act sets out a priority list of persons who may consent in such circumstances:
1. A person authorized by the court (e.g. a curator); or
2. In order of priority, the patient's spouse, partner, parent, grandparent, major child or brother or sister.
3. Health care practitioners should also consult the provisions of the Mental Health Care Act (Act No.17 of 2002) when dealing with mentally ill patients.
Apart from the legal requirements, the following issues should be taken into consideration when assessing what might be in the best interests of a patient. It may also be useful to determine who has an interest in the care of the patient and whether such people should be involved in discussions so as to respect the patient's right to privacy and confidentiality. It is usually beneficial to share any 'best interest' decision with those responsible for the patient's care.5
- The patient's values and preferences if they were known to have been competent at some time in the past
- The patient's psychological and spiritual well-being
- The patient's physical well-being
- The patient's overall quality of life
- The relationship and impact of the patient's condition on family and carers.
In cases where the patient's request for extractions is not based on rational considerations, the dentist's advice and recommendation is also important. This is especially relevant in South Africa where the concept of autonomy is not fully developed and where patients still place high value on the advice of their dentists. In advising patients, it is essential that the dentist is always motivated by the patient's best interests.6 Specific time needs to be set aside when eliciting informed consent and for complicated scenarios it may be necessary to provide written patient information. Competent patients can make 'wrong' decisions. Provided the condition is not life threatening and the patient is not ignorant and uninformed, an informed 'wrong' decision should be respected.4
As a profession we have a duty to weigh up the benefits and risks of any procedure, and if the potential harm outweighs the benefits, even patients requests for treatment should be declined. The role of the dentist in educating such communities is crucial and a reflection of the principle of beneficence. When dentists are approached with irrational requests, they have an obligation to counsel and discourage unnecessary treatments, and in these situations paternalism is justifiable. Dentists must be aware of the ethical and dento-legal risks that accompany requests for irrational treatments and the solution is to counsel the patients, and inform them fully in the consent process.
1. Broers DLM, Brands WG, Welie JV, de Jongh A. Deciding about patients' requests for extraction: ethical and legal guidelines. J Am Dent Assoc. 2010; 141(2):195-203. [ Links ]
2. Shuman SK, Bebeau MJ. Ethical and legal issues in special patient care. Dent Clin North Am. 1994; 38(3):553-75. [ Links ]
3. South African Parliament. National Health Act of No 61 of 2003, Chapter 2 Section 6. Pretoria. [ Links ]
4. Ethics, values and the law. DPL Dental Ethics Module 8: Patient autonomy and consent. 2009 [ Links ]
5. Health Professions Council of South Africa. Guidelines for Good Practice in the Health Professions. Booklet 9: Seeking patients' informed consent: the ethical considerations. Pretoria, 2009. [ Links ]
6. Moodley K, Naidoo S. Ethics and the Dental Team. Van Schaik Publishers, Pretoria, 2010. [ Links ]