8 MINUTE READ

From Luke’s Journal June 2024  |  Vol.29 No.2  |  Christian Hospitality

It’s a Monday morning and you see your first patient of the day: a new patient scheduled for a check-up and clean.

The patient comes in and opens with, “That last dentist I saw was just drilling teeth so they could pay off their new Lexus”.

I’m sure many of us have heard it time and time again.

While the majority of such claims may be tall stories, have you ever stopped to think how much power and autonomy dental practitioners (or any practitioner in a highly specialized field) hold? Ever thought how easy it is to manipulate vulnerable people (patients who are in pain and are afraid) into consenting to invasive treatment that will cost them thousands, even tens of thousands of dollars? I’d be lying if I said I hadn’t been tempted, or even actually overserviced a patient myself, fuelled by financial gain or pressure to meet KPI’s. If you’re a dentist, have you ever been tempted to take intra-oral photos of teeth that have stains around existing fillings that look worse than they are, enlarge them so they fill the computer monitor in front of the patient, and try to convince the patient (and yourself) that the tooth is not stable unless it is held together by a crown?

The Four Principles of Ethics in Clinical Practice

Before proceeding any further, it is important to note the four fundamental principles of ethics:  beneficence, nonmaleficence, justice, and autonomy, and how they apply to clinical dental practice¹. Beneficence is the duty of the practitioner to act in a manner that benefits the patient¹. Generally, this involves removing the source of pain affecting the patient and providing treatment that will improve their condition (such as removing a heavily infected tooth). Nonmaleficence is the duty of the practitioner to do no harm, and together with beneficence, provides patients with the best treatment for their ailments¹. Justice in a clinical setting is the equitable treatment of all patients, removing all bias or prejudice when providing treatment¹. The basis for the principle of autonomy is that all people have unconditional worth, and thus, must be afforded the power to make rational decisions for themselves¹. Autonomy does not apply to those that lack the capacity to act autonomously (such as minors, or those with a mental or physical impairment). The principle of autonomy forms the foundation for informed consent, where patients must have the competence to understand and make decisions, have been given full disclosure of all necessary information, have shown the ability to understand the given information, and have acted on their own volition¹.

Clinical Beneficence over Justice and Autonomy?

I have been to a few Continuing Professional Development (CPD) courses, designed to maximise profits by changing the way dentists communicate to patients. I was taught that by structuring the way practitioners present treatment, they are able to essentially guide patients toward “ideal” treatment. Ideal treatment was taught to be the best possible treatment for a particular problem if money were not an issue. Scripts were given to participants to memorise, noting the order in which to present treatment, what key words to use, and phrases to avoid. Participants were even advised how to position themselves in the room for maximum effect. The lecturer then promised that if said techniques were utilised, one would see the number of crowns (a highly profitable dental procedure) that they performed in a week increase dramatically. Now, I agree that learning the art of case acceptance is a useful tool to help patients improve their oral condition. However, it is a tool that can be easily abused. Dentists and other specialised practitioners are rarely monitored when they present treatment to patients, and can easily steer them towards the most extensive treatment options. It is the practitioner’s job to inform patients and help them understand the extent of their condition/ailment. They must present treatment options without bias, thereby allowing patients to make an informed decision. The AHPRA (Australian Health Professional Regulation Agency) Shared Code of Conduct for Health Professionals² states that treatment should be patient-centred, and that it should aim to meet the best possible outcome. It mentions that practitioners must work with patients through effective communication and build trust with patients in order to allow patients to understand and participate in the care they are to receive². I believe that the best possible outcome doesn’t always have to equate to the most extensive and expensive treatment.

“…the best possible outcome doesn’t always have to equate to the most extensive and expensive treatment.”

Although it is our duty of care to present all treatment options, especially when pertinent to the overall health and well-being of the patient, it is equally important not to give weight to elective or non-urgent needs. I honestly do not believe that such a high proportion of patients require crowns when their existing fillings have been sound for many years. In the past, I have been advised by previous employers to “convert those amalgams into crowns”, and “see every checkup and clean as an opportunity”. This opportunistic approach goes against the principles of justice and autonomy. Losing a second lower left molar is not the end of the world, especially if it is the only tooth that the patient is going to be missing. Dentists, however, are taught to tell patients that losing a tooth is “like pulling a book out of a bookcase – you take one out and the rest collapse in”. We are taught to exaggerate the problem. Putting a crown on every single tooth that has a large amalgam restoration (even though they have been asymptomatic for 25 years) puts heavy emphasis on dental beneficence (the best possible dentistry available for a given problem). However, it may not be the most beneficial treatment for the patient if the extensive dental work causes financial stress and causes the patient to withdraw from their superannuation. By overemphasising dental-specific beneficence in this instance, the patient’s autonomy is hindered as they are guided toward a pre-planned treatment option that will financially benefit the practitioner under the guise of beneficence. Therefore, justice does not prevail, as prejudice has taken over.

Do No Harm

Now in my seventeenth year of dental practice, I have seen a shift towards dentists wanting to perform increasingly more complex treatments themselves. When I graduated from dental school in 2007, many general dental practitioners would not dream of treating patients with fixed orthodontics, placing their own implants, and doing full mouth rehabilitations with implant-retained hybrid bridges (e.g. “all-on-4”, “all-on-X”, etc.). I have been pressured (“encouraged”) by previous employers and even by peers to upskill in such areas. Some practitioners may be motivated by a desire to learn new skills, and others by a genuine fascination with dentistry. However, I would say a majority of those wishing to upskill in these lucrative areas would be doing so in hopes of better remuneration in the future. Although I believe having a passion for dentistry and maintaining CPD requirements is necessary, I also believe that a competitive culture of ‘one-upping the dentist across the road’ can be dangerous, and can lead to dentists performing treatments that are beyond their capabilities. Therefore, there is a greater risk in the community for general dentists to break the principle of nonmaleficence, and cause iatrogenic damage to patients. Providing the best treatment for patients, in my honest opinion, often requires eating humble pie, and knowing when to refer, either to a colleague or a specialist. 

Be a Hospitable Practitioner

What does any of this have to do with hospitality? We as hosts (practitioners and staff), especially as representatives of Christ, should be caring towards our guests (our patients), and act in their best interests. I challenge each of you to start each day by asking yourself – am I being the best example of Christ in my workplace in the way I present and provide treatment to my patients? Our staff are observant and have a good insight into the types of people we are by the way we conduct ourselves at work. The receptionist knows that Dr A charges like a wounded bull, while Dr B seems to be fair and equitable in their approach to treatment planning.

The Apostle Paul writes to the Colossian church and instructs them “Whatever you do, work at it with all your heart, as working for the Lord, not for human masters, since you know that you will receive an inheritance from the Lord as a reward.” (Colossians 3:23-24 NIV).

Are we practicing what we preach to our kids, our Sunday school students, and our congregations within our surgeries?

Are we providing genuine care for our patients in the treatment that we provide, and doing what is truly best for them?

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References

1. Varkey, B. Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract. 2021 Feb; 30(1): 17-28. Available from: URL https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923912/#:~:text=learning%20and%20research).-,Nonmaleficence,of%20the%20goods%20of%20life
   
2. AHPRA. Code of Conduct Principles. Available from: URL https://www.ahpra.gov.au/Resources/Code-of-conduct/Resources-to-help-health-practitioners/Shared-Code-of-conduct-principles.aspx