ETHICS

 

Trust me - I'm a Doctor

 

 

LM Sykes^I; L Matshego^II; V Bookhan^III

^IBSc, BDS, MDent, IRENSA, Dip Forensic Path, Dip ESMEA, Head of Department of Prosthodontics, University of Pretoria. Orcid nr: 0000-0002-2002-6238
^IIBTech Dent Tech, BDS, Department of Prosthodontics, University of Pretoria
^IIIBDS, MDent,Department of Odontology, University of Pretoria. Orcid nr: 0000-0002-4235-3897

Correspondence

 

 

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ABSTRACT

A professional has a job that needs a high level of education and training, and who acts in a manner that conforms to the technical and ethical standards of their profession. They are also expected to adhere to a specific set of duties known as professional ethics and competencies.
Many duties are common to most professions such as honesty, integrity, transparency, accountability, objectivity, respectfulness and obedience to the law. In medicine and dentistry there are additional duties related to all aspects of patient care and workplace interactions. In this paper the duties of a doctor will be discussed under the categories of legal duties, business-related duties, professional duties, clinical duties, educational duties, the duty to work, and moral / ethical duties.
While it is recognised that practitioners have a right to practice their trade as a result of their professional education and training, they are also obligated to behave in a manner that will uphold the reputation of their discipline. At the same time, patients have the right to expect and to receive the best possible care but need to also take care of their own health and follow the advice given to them by their doctors.

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INTRODUCTION

A professional has been defined as a person who has the type of job that needs a high level of education and training¹, and who acts in a manner that conforms to the technical and ethical standards of their profession². Professional responsibility refers to the "set of duties within the concept of professional ethics"³. They are drafted for those who are required to "make judgments, apply their unique skills, reach informed decisions for, or on behalf of others, and to exercise due care and responsibility when acting in their areas of specialization⁴. It "encompasses an array of personal, corporate, and humanitarian standards of behavior, as expected by clients, fellow professionals, and professional bodies"⁵. These standards are usually structured into guiding documents, commonly known as the "code of ethics". The purpose of which are to establish a general blueprint of the expected ethical standards that will assist professionals and organizations in implementing and governing the ideals of the profession⁶. Although intended for use by professionals when they are engaged in applying their unique skills in their career, the same ethical and professional principles should also be applied in matters relating to their individual character, demeanor, and personal life⁴.

They may also help persons decide on how to act in different situations, by directing them to debate options using ethical perspectives that encompass their academic training, clinical experience and judgement, as well as "virtues, values, rules, ethical theories, moral stances, moral decisions and moral compasses" ⁷.

There are certain generic responsibilities that can be applied to almost all professions these include:

• Honesty - being trustworthy, loyal, sincere, and fair

• Integrity - showing consistency between actions, values, expectations, and outcomes

• Transparency - operating in a manner that allows others to see what actions are performed

• Accountability - taking responsibility for actions and their outcomes

• Objectivity - having a well-informed unbiased view on practical matters

• Respectfulness - treating colleagues and clients with care and compassion

• Obedience to the law - adhering to regulatory and governmental guidelines⁷

In addition to these, in medicine and dentistry, there are other competencies and duties related to the ethical, legal and clinical aspects of patient care as well as workplace principles that inform on matters related to, amongst others, interactions with staff, colleagues, peers, company representatives and third-party funders.

Duties of a Doctor

Medical and dental students undergo many years of structured academic study and clinical skills development before being awarded the title of "Doctor". This designation gives them the right to practice their profession, and brings with it a certain amount of public honour, respect and trust. However, in order to live up to this reputation, they need to be aware that their rights as a professional carry with them certain responsibilities and obligations.

These can be considered "Doctor's Duties". While these duties cannot make demands in matters of taste, personal preferences, personal choices and personal lives, they do apply to all matters affecting the common good of society⁸. Professional duties can fall into a number of different categories including: legal, professional, clinical, educational (self-improvement and education of others), moral / ethical, business-related conduct, and duty to work⁸. Many of these core values and duties fall into more than one category, but will only be discussed once.

Legal Duties

Core values and responsibilities relate to Confidentiality, Competence, Honesty and Professional Courtesy. Legal duties compel professionals to know and adhere to the laws of the land as well as the specific laws stipulated by their professional governing bodies. Ignorance of the law can never be used as a justifiable or defensible argument for non-compliance or misdemeanours⁹. Confidentiality revolves around the special doctor: patient relationship, wherein anything discussed or revealed during a consultation should not be disclosed to any third party.

There is however, a legal over-rider that permits the doctor to breach confidentiality if they believe that their silence may put the patient, themselves, another person or the community in danger of harm, or when compelled to do so by a court of law¹⁰. When considering competence, the clinician should only carry out work they have been trained to do, providing they are also skilled enough to do so. Furthermore, it requires them to engage in a process of continuous and honest self-assessment and reflection. If they suspect or detect any personal mental, physical or emotional deterioration, they are ethically obliged to adjust their scope of work or even stop practicing altogether¹¹. This may be on a temporary or more permanent basis. Honesty relates to their duty to do what is in the best interest of their patients at all times. It covers the ethical issues of patient education, autonomy and informed consent and will be discussed later.

It also refers to honesty with regards to finances. For example, they may only bill for services provided, fees should be in accordance with those suggested in the government gazettes, unless they can justify why they deserve more, and should submit legitimate claims to third party funders. They must also maintain accurate and comprehensive records, be honest when issuing sick certificates and writing out prescriptions, and avoid all forms of legal misconduct¹².

Business-related Duties

Core values and responsibilities- Integrity, Teamwork, Objectivity, Honesty

While medicine and dentistry may be professional vocations, they are also the clinicians' livelihood and as such may be considered as businesses as well. Thus, all of the codes of conduct related to running a business will apply to running a practice. Many clinicians work for themselves, meaning that they will not have to answer to a higher manager, or have a superior watching over them. This could make it easy and tempting for them to act in a manner that will primarily benefit their own pockets. Personal integrity and conscience are arguably the most central qualities that will determine how they chose to conduct their business. Honest practice covers so many diverse issues, such as:

• the hiring of adequately trained staff;

• paying fair wages;

• not expecting employees to work unreasonable hours (unless they agree and are compensated for this);

• providing patients with the necessary and most appropriate treatment;

• avoiding the temptation to over-service;

• correct billing and handling of finances;

• avoiding split-billing, medical aid abuse or medical aid fraud;

• using integrity and good judgement when writing up prescriptions and issuing sick letters;

• not succumbing to perverse incentives offered by manufacturers and supply companies;

• and avoiding any form of conflict of interest to name just a few¹².

Ultimately personal character is what will determine how a person behaves when nobody is watching.

Professional Duties

Core values and responsibilities - Professional Courtesy, Competence, Awareness of limitations, Practicing within scope of training, Expertise and Professional qualification, Legal advertising and justifiable self-promotion Professional courtesy relates to how clinicians interact with their peers, their patients, and the public. It is generally more of an ethical than legal duty, but may fall into the latter category if they publicly slander or malign the reputation of a colleague. However, if they do detect any form of impropriety or incompetence in one of their peers, they should be brave and honest enough to first approach that person and offer help or remediation (this is ethically desirable). If collegial discussions do not elicit any change in behaviour they are obliged to report the misconduct¹³. They need to also be aware of the manner in which they address others, and strive to treat all patients as equal. (Competence, Awareness of limitations, Practicing within scope of training, Expertise and Professional qualification are all discussed in clinical duties below).

With the explosion of social media access, many clinicians have also taken to this platform to post practice-related material. This could have been an ideal avenue for the profession to promote oral health and educate the public, but has unfortunately become more of a channel for self-promotion, or worse, dissemination of mis-information. An increasing number of dentists are posting "before and after" photographs of their work and offering to provide similar spectacular make-overs to others.

This is tantamount to advertising, a practice that has always been frowned upon amongst medical professionals. It is concerning to note that these posts not only create unrealistic and at times false expectations amongst the public, but also seldom elaborate on the practical issues of costs, and the potential biological and socio-economic risks associated with the procedures. Neither do they provide adequate details on maintenance requirements, and possible complications. Very few (if any) show long term follow-ups^14-16.

There are even sites where practitioners offer special deals such as "family discounts", "early bird promotions", "bring a friend and get two for the price of one offers" or "special wedding packages". Almost all of these procedures are purely cosmetic in nature with no justifiable clinical need or indication for the intervention.

A more disturbing observation is the increasing number of dentists who are offering services outside the scope of practice, beyond their levels of training and expertise or even outside of the profession altogether. There are general dentists offering full mouth make-overs in a few short visits (even same day service), yet prosthodontists may take weeks or months to complete the same treatment, especially when it involves major changes, in patients with complex parafunctional habits, in those needing multidisciplinary treatment planning and work, or cases where there will be adjustments in vertical dimensions and occlusal schemes.

There are also sites that make claims of therapeutic benefits that have no scientific backing, and where treatment could even do more harm than good. Two recent examples include a dentist who claims that skew teeth need to be straightened because "overlapping teeth trap more food and cause more cavities; your speech will be more fluent and clear with straight teeth; eating tough meat like steak will be easier; crooked teeth are prone to break easier; you get fewer headaches with straight teeth; your gums will be healthier; your overall health will improve; you will need less expensive dental treatment later in life; and of course, you will have a better self-esteem".

The second site offers to provide "slimming wires as a weight loss method". In essence they put orthodontic bands on all the teeth and then wire the jaws shut. What about oral hygiene? Potential tooth damage? Psychosocial implications? Cost and time duration? How will this address and improve long term eating habits? Where is the scientific evidence and proof that this treatment modality works? And what to do in the event that the patient chokes, aspirates an object or regurgitates? Such practices amongst our colleagues cannot be condoned and need to be challenged¹⁷.

Finally, when considering the ease with which the public can access and share posts from Internet sites, it is important for clinicians to be careful of the image they portray. Private chats and personal groups are seldom exclusive, and one ill-advised comment can easily be taken out of context and spread widely. They need to be aware that any actions or words spoken in their private lives can so easily end up affecting their professional life and reputation as well¹⁷.

Clinical Duties

Core values and responsibilities - Trust, Do No Harm, Privacy, Competence and awareness of limitations, Practicing within scope of training, expertise and professional qualification, Avoiding improper relations with patients (in person and on social media sites), Social accountability and Provision of appropriate treatment

Clinical duties are primarily patient related and fundamentally based on the doctrine of "first do no harm" as outlined in the Hippocratic oath¹⁸. These cover a range of issues such as communication, confidentiality, the patient's right to high quality of care, provision of the most appropriate treatment, completeness of work, professional courtesy, trust and honesty, beneficence, non-maleficence, respect for patient's autonomy, awareness of personal limitations and scope of expertise, and the insight and ability to know when to refer a patient for a second opinion or to a more skilled clinician^19-24.

From a practical perspective they relate to the physical oral environment and adherence to the laws of mechanics, physics and biology. They cover all aspects of the actual work carried out in the surgery as part of the patient's definitive treatment.

Educational Duties

Core values and responsibilities- Consideration, Growth, Communication, Continued professional development, Patient consideration, Patient education Educational duties fall into two main categories, the first relates to continual self-improvement and life-long learning, while the second refers to the duty to educate the public. In the former, clinicians are expected to keep up to date with current literature, techniques, materials and trends, and to adapt their practices if and when it becomes necessary. In an attempt to try and enforce this, the HPCSA implemented compulsory Continual Professional Development (CPD) requirements. While it is a legal requirement for practitioners to earn CPD point on a yearly basis in order to be allowed to practice, one hopes that they also have the moral compass to not just treat this as a necessary evil, but to see it as the valuable learning and self-improvement tool that is set out to be^{25, 26}.

It also relates to the altruistic aspects of being a professional such as providing education and preventive services to the public, and sharing of knowledge and skills with colleagues through responsible communication in workshops, CPD events, chat groups and via research and publications^{7, 27}.

Duty to work

Core values and responsibilities- Duty to self and Society, Integrity, Teamwork.

We all need to work in order to earn a living and survive financially. However the duty to work has many more practical and philosophical layers. Being able to work and generate an income provides one with a sense of dignity, it can be a form of self- expression and creativity, and it may be transformative in that it could help others, could add to technological progress or may serve to change (hopefully Improve) the environment. At the same time, education is a privilege. Having spent time and money on gaining a degree, one is ethically obliged to give back to society by working in the profession of one's training. In medicine and dentistry this entails treating patients who are in pain, who have infections, who are ill / in need of therapy, or who seek some medical intervention to improve their physical or psychosocial well-being and state of health.

It would be ethically pleasing if clinicians, in addition to performing their core profession of being doctors, could include an altruistic element into their work, where-in they "give back" to society. This may be by providing voluntary services, taking part in outreach programmes, helping with community up-liftment projects, providing public screening and education, or by contributing to any number of other similar societal programmes. Finally, for those who believe in any form of higher power, work allows them to honor their creator by using their talents to their fullest.

Moral / Ethical Duties

Almost all of the aforementioned core values and responsibilities are also ethical duties, along with many others. Ethical duties encompass Confidentiality, Competence, Professional Courtesy, Trust, Non-maleficence, Privacy, Integrity, Respect for patients and peers, Consideration, Communication, Obligation of continual self- development, Self-reflection, Beneficence, Respect for the patients' rights to autonomy, Social accountability and Community engagement and service

 

CONCLUSION

Medical and dental practitioners have a right to practice their trade as a result of their professional education and training. With this right comes a duty for them to behave in a manner that will uphold the reputation of their discipline, and to live up to the respect and trust that their patients and society have bestowed on them. Their patients in turn, have the right to expect and to receive the best possible care from their treating doctors. However, they too have certain duties, such as to take care of their own health and oral hygiene status, and to follow the advice given to them by their doctors. Both parties need to fulfil their specific duties related to their respective rights in order to build and maintain a just and stable society.

 

REFERENCES

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Correspondence:
Leanne Sykes
Email: Leanne.sykes@up.ac.za

 

 

Author contributions:
1 . Leanne M Sykes: 70%;
2 . Lebogang Matshego 15%
3 . Vinesh Bookhan: 15%