Ethics are the moral principles or virtues that govern the character and conduct of an individual or a group, as a branch of both philosophy and theology, is the systematic study of what is right and good with respect to the character and conduct. [1] Ethics is the understanding and the ability to differentiate right from wrong in human behavior [2] The field of ethics, along with aesthetics, concerns matters of value; these fields comprise the branch of philosophy called axiology [4]
The code of ethics in dentistry warrants an orthodontist to act in the best interest of their patients regardless of their financial status, even putting themselves at jeopardy if need be.
Etymology
The etymology of the term “Ethics” is from the Greek word “Ethikos” which means character or conduct. [3] It is typically used interchangeably
with the word moral which is derived from the Latin word mores, which means customs or habits.
Background
Both medical and dental specialties consist of various ethical principles and values which are strictly followed and respected.
Although,it is not every day that an orthodontist faces life or death situation in their practice, however, they deal with important human values which are at stake during the course of orthodontic treatment. Some of these include, pain prevention and management, preservation and restoration of oral function for normal speech and mastication, preservation and restoration of patient’s physical appearance, and enhancing a sense of control and responsibility over their health.[5] Orthodontists also manage a large number of pediatric patients and adults and may encounter ethical issues to provide the best treatment option for the child or adult, help in surrogate/guardian decision making, and enable access to care. Declaration of Helsinki is used as a statement of ethical principles to provide guidance to physicians. [10]
Ethical Principles:
Ethical problems usually arise when there is an uncertainty or conflicting moral obligations.
The orthodontist should be aware of the ethical principles present for clinical decision making in their practice . The aim of these codes is to enhance
a sense of ethical responsibility in order to ensure the highest level of professional and ethical consciousness to maintain a standard of decision making and conduct. [6]
The major principles include: [7]
- To do no harm (non-maleficence)
- To do good (beneficence)
- Respect for persons
- Justice
- Veracity or truthfulness
- Confidentiality
The American Dental Association principles of Ethics and Code of professional conduct (ADA Code) have given five fundamental principles, which form the foundation of ADA code.
- Patient autonomy
- Non-maleficence
- Beneficence
- Justice
- Veracity
Patient autonomy (“self-governance”)
The patient should be explained about different plans and should be given
full autonomy as he/she is capable to take her own choice. if the patient is a minor then the parent or guardian should make the decision about how to be treated. One should not force her to go for expensive treatments because of more monetary benefit to the practitioner, when a patient is in need of
camouflage treatment and have decided to go on with it, never force them to get skeletal corrections done.
Under this principle, the dentist’s primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient’s need, desires and abilities, and safeguarding the patient’s privacy. [8]
Non-maleficence (“do no harm”)
This principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle, the dentist’s primary obligations include keeping updated knowledge and skills, knowing one’s own limitations and when to refer to a specialist or other professional, and knowing when
and under what circumstances delegation of patient care to auxiliaries is appropriate. [8]
Beneficence(“do good”)
This principle expresses the concept that professionals have a duty to act for the benefit of others. Under this principle, the dentist’s primary obligation is
service to the patient and the public-at-large. The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due
consideration being given to the needs, desires and values of the patient. The same ethical considerations apply whether the dentist engages in fee-for-service, managed care or some other practice arrangement. Dentists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their
ethical duty to put the patient’s welfare first. [8]
Justice (fairness)
Irrespective of patient’s lower socioeconomic status, when the patient is ready to pay for orthodontic treatment he/she has to be treated with camouflage including retention period.
As per AAO’s Principles of Ethics and Professional Code of Conduct, Section VI, states, “Members may exercise discretion in selecting a patient into their practice, provided they shall not refuse to accept the patient because of the patient’s race, creed, color, sex, national origin, disability, HIV seropositivity
status or other legally recognized protected class.
This principle expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues and society. Under this principle, the dentist’s primary obligations include dealing with people. Justly and delivering dental care without prejudice. In its broadest sense, this principle expresses the concept that the dental profession should actively seek allies
throughout society on specific activities that will help improve access to care for all.
Veracity (truthfulness)
This principle expresses the concept that professionals have a duty to be honest and trustworthy in their dealings with people. Under this principle, the
dentist’s primary obligations include respecting the position of trust inherent in the dentist-patient relationship, communicating truthfully and without
deception, and maintaining intellectual integrity.
Informed consent
Informed consent is one of the central concepts of present-day dental ethics, implies that the process of securing consent from a person meets the equired
standards. It implies that the person from whom consent is sought should have adequate reasoning ability, a clear understanding of the facts, a good idea of the choices available, an appreciation of the implications and comprehension of the consequences [9]
Ethics in Orthodontics
Inform Before Perform: Once the patient has decided to do an orthodontic treatment, details of the proposed treatment plan from the start to end and the retention phase must be explained. The information should be conveyed in a rational easily understandable language without much usage of
complicated dental jargons. This can be done using handheld models, patient casts or even showing improvement in Extra oral and Intra oral photos of progress and post orthodontic treatment using latest digital software or simple apps for making composite images. Orthodontist can send the periodic progress photos to the patient or parent to keep them motivated. This essential step before the start of active treatment is useful in encouraging and motivating patients towards the treatment, thus gaining their trust towards the orthodontist. Internet can be used to show them appliances they are going to wear during the treatment and ask them to do research about them. This is essentially educating the patient.
Right to choose: The orthodontist does not entirely make decisions regarding orthodontic treatment. That is called patronizing. They are required to respect the moral and legal authority of the patients and incase of pediatric patients, the parents. [11] Various treatment options, and its pros and cons if any, should be informed and clearly explained to the patients prior to the treatment. Orthodontist should respect patients’ rights and give them the freedom to decide upon their treatment. Patients must be given full authority in the decision making process and must not be forced to make a decision that is favored by the orthodontist.
Benefit/Risk ratio: The treating orthodontist must first understand the treatment needs of the patient in depth to have a clear view of the type of treatments for them. Any orthodontic treatment may have certain benefits and risks and/or limitations associated with it. Alternative treatment plans options with lesser risks, if any, should expalined to the patients to decide, which will benefit their oral function, appearance, and quality of life, rather than not doing any treatment. Orthodontists have a moral obligation to support patients’ interests and to do no harm.
The course of treatment duration: Total time taken for completion of orthodontic treatment depends on the severity of malocclusion.[8]Patients should be informed about the treatment duration earlier to start of treatment
as the time taken for completion of extraction cases is more than non-extraction cases. Estimated treatment time predicted by an orthodontist can be delayed due to secondary factors like irregular or missed appointments
and/or broken appliance or debonded brackets. In case of increase in treatment duration due to the secondary factors the orthodontist should differentiate between their responsibility and that of patients, thereby encourage them to be more regular and responsible towards their
treatment.[13]
Retention Phase: Before removal of orthodontic appliance, the case should be finished in good occlusion without premature occlusal contacts to ensure long term stability. Post active treatment, retainers should be given with instructions on their timely wear to prevent relapse. Importance of retainers in maintaining the corrected malocclusion should be informed prior to the start of treatment and should be emphasized on the duration of wear post active treatment. Patient cooperation in wearing retainers is vital for maintaining the achieved results. Retention is an important, even critical, component of orthodontic treatment. There is little research on practice protocols and patient compliance with long-term or short-term retention. This lack of information leaves our specialty with many opinions and practice protocols.[13]
Informed consent: According to the guidelines laid down by the American Association of Orthodontists, an informed consent ought to include details such as treatment results and duration, presence and level of discomfort, risk of relapse, extractions and orthognathic surgery, possibilities of decalcification and dental caries, root resorption; periodontal diseases; risk of temporomandibular disorders, status of impacted and ankylosed teeth, allergies and usage of temporary anchorage devices in treatment. The orthodontist should attach documents of acknowledgement, a consent
form and an authorization letter for the usage of patient information and their treatment records in case of future publication.
Medicolegal Concerns: It is the medicolegal responsibility of the orthodontist to take radiographs and photographs of the patient before the start of the treatment, after getting a clear consent from them. These records are useful for screening any pathologies or anomalies, planning treatment mechanics for achieving best results, comparison of treatment results achieved and to get a second opinion if needed. Patients records must be filled and maintained in good condition even after orthodontic treatment. Using patients records, especially extraoral photographs for publication and research should be done only after patients’ written approval. [14]
In case of referral of the patient to another orthodontist the copy of the patient’s record must be saved. A detailed history of the patient, treatment plan and the progress of the treatment so far has to be transferred to the referral orthodontist. This must be done to ensure that no difficulties are faced both by the orthodontist and the patent in finishing the treatment. A clear and detailed consent should also be enclosed form both the parties.
Similarly, if the patient wants to discontinue the treatment due to personal reasons, orthodontist should explain the ill effects of incomplete treatment in case of extraction, and chances of relapse. Patients written consent should be obtained before removal of the appliance. [15,16]
The codes of ethics require an orthodontist to act in the best interest of patients regardless of their financial status.[8] Abiding by these basic ethical codes will not only give simple moral justification in their duty as an orthodontist but also will protect them legally as a professional in providing the best healthcare to the community. [17]
