As dentists, we are responsible for all the choices we make regarding the kind of services to accord our clients as well as the choices we make for other professional duties. In our practice, we are often confronted with a number of conflicting alternatives that are likely to result in differing consequences of almost similar emotional, physical and professional magnitude, regardless of the way we choose to go. In this regard, ethical dilemmas are complex situations or scenarios involving two or more sort of transgression or conflict and for whichever choice made, consequences are inevitable. Such scenarios often result into cognitive dissonance, which is the moral anxiety that is brought about by the difference in perceiving an ideal scenario as opposed to the reality itself.
Despite the complex nature of ethical dilemmas, solutions have to be sought through creativity, subordination of one’s interests to the professional codes of ethics, involvement of the client in the process of decision-making to determine the efficacy of a given solution, protection of mutually shared interests among other measures. Below is a representative dental scenario that would require critical application of a number of measures to solve an ethical problem.
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Ethical Scenario of Dilemma in Dentistry
After the process of scaling and root planning, the dentist legally delegates to an expanded functions dental assistant two tasks which involve polishing clinical crowns of teeth and application of fluoride varnish before the patient can finally be dismissed. In the course of the coronal polish procedure, the dental assistant detects a large area of calculus subgingivally extending on the mesiolingual of the tooth number 26. There are three choices involved: First, the dental assistant can pick up a scalar and simply remove the calculus as a professional dentist would do. The second choice would be to call the dentist who is currently attending to a different patient to come and remove the calculus and delay the other patient or alternatively, the dental assistant can simply disregard the calculus and leave it in place.
Steps in Solving Ethical Dilemmas
There are four steps involved in professional consideration and solution of an ethical dilemma. These steps, as detailed by (Dörries, 2009), include: presentation of the situation, situation analysis, exploration of alternatives and the choice of the best alternative. These steps are briefly detailed below:
Step 1: Presentation of the Case
The case is presented to the professional consultant by the dentist, dentist assistant or any other person concerned. The relevant medical and professional facts are then explored to find out the best course of action. At this stage, dentists should reason about the medical indication for handling the scenario as well as the present situation of the patient or client. The legal situation involved should also be considered paramount since it provides the guiding principles to the practice of dentists. If these factors cannot be cleared, then there is need to postpone the situation until further consultations are done.
Step 2: Situation Analysis
This step involves ethical judgments and argumentations. The dentist at this stage is expected to reflect not only on the situation at hand but on the underlying facts and information about the situation. This is the time to think and brainstorm any other similar situation that has once occurred in one’s profession or practice. In so doing, there is need to limit case analysis to medical terms, language and limitations. This implies the role of professionalism in trying to contemplate a possible solution to the dilemma. There is need to analyze all the norms behind the argumentations. At this point, the participant is supposed to base the judgment on nursing, medical or clinical perspective. For instance, there is need to prioritize the interests of the patient. If a moderator is involved in the argument, this is where he/she has to clarify the underlying norms. The relevant arguments and alternatives can then be weighed, compared and balanced in relation to the situation at hand. Basically, ones success at this stage is the critical ranking of values and alternatives which, in one’s own professional judgment, are most relevant to the issue or dilemma. For instance, it is worth musing over the question: What are the reasons for prioritizing one competing value or principle over another?
Step Three: Exploration of Alternatives
At this stage of dilemma solution, alternative solutions are considered for discussion or analysis. This often involves possible consequences of any of the available alternatives. Arguments and facts sought in the second step are applied at this stage. This step is important because it validates whichever decision that will be considered, based on the relevant facts and their professional or legal background. Therefore, regardless of how others may view one’s decision, chances of facing condemnation or rejection are very low. Additionally, an alternative at this point does not meet outright rejection from the expert or colleague because it is based on valid grounds. Alternatively, multiple solutions to a single problem can be combined or new ones can be tried out. The most important element of this stage is the development of an action plan that is consistent with ethical priorities that have already been determined as central to the dilemma at hand. Be certain that to confer with the colleagues and the client, as appropriate, about the potential consequences or risks of alternative courses of action. Similarly, the action plan should be based on sound ethical values and principles.
Step Four: Solution of the Dilemma
This is the point of taking a sound action towards the solution of a dilemma. If there are two or more people involved in solving particular dilemma, there is need for mutual agreement and consensus before an action can be taken. This step often ends with a consensus about the best one among the solutions discussed or brainstormed. The solution being taken without mutual agreement and consensus can rarely be effective. The results are then summed up and if necessary, tasks are appointed. Generally, this step involves consideration of options that would be ethically appropriate, consideration of the possible positive and negative outcomes of each possible option and consequent application of the solution.
If the above steps of solving a dilemma in dentistry are keenly considered, there are minimal chances of facing negative consequences in one’s profession and even if they occur, the dentist is separated from those consequences and instead, there is shared responsibility in bearing those consequences (Purtilo & Doherty, 2015).
Solution of the Dilemma in the Scenario
Considering the above described steps involved in solving ethical dilemmas in dentistry, the above ethical scenario can be solved as follows:
The proper response would be to call the dentist for the removal of the calculus. This is because dental assistants are generally not allowed by the law to remove calculus, especially it is subgingival calculus. However much easy it might seem to remove it, if the dental assistant chooses to do it, he makes a choice of breaking the law. According to Pozgar (2014), any health practice restricted to a particular health specialist should be accomplished by that particular specialist alone. If the dental assistant chooses to remove the calculus, then there is both legal and professional implication that exceeds the health implication of carrying out the practice.
Another alternative to this dilemma would be leaving the subgingival calculus in place, considering the fact that the dentist is busy attending to a different patient. In regard to the patient’s needs and interests as well as professional ethics, the dental assistant is responsible of ensuring client safety. Since leaving the calculus in place would result into possible harm to the patient because periodontal inflammation would continue in that area and worsen the patient’s dental health, it is neither ethical nor professional to leave the subgingival calculus in place.
In this scenario, although the right one can be chosen (calling the dentist), a conflict will occur since a delay will also occur, leading to the possible compromise of the schedule. Pozgar (2014) asserts that the true “lesser of the evils” or moral choice has to be made, even though the choice might not result in the ultimate solution of the problem or achievement of the ideal situation.
Other options available apart from the above discussed options would be to refer the patient to a different dentist who might not be held up at that time or postpone the removal of the calculus until later on when the dentist is free. However, none of these options would be as appropriate at as the option of calling the dentist to attend to the problem.
Generally, dilemmas in dentistry are complex issues that often confront dentists and other health professionals in the field and can be solved by any of the conflicting solutions both of which have potential risks. In the above case involving the dental assistant’s dilemma of whether to remove the subgingival calculus or call the dentist who is currently held up in a different task, it is seen appropriate to call the dentist and rather delay his schedule than apply any other solution. This is in line with the four major steps of solving professional dilemmas in health care as detailed above. The solution proposed would result in lesser harm compared to all other options available, which is the ultimate goal of health care.
References
Dörries, A. (2009). The 4-Step Approach. Ethics case discussion in hospitals. Diametros , (22), 39-46.
Pozgar, G. D. (2014). Legal and ethical issues for health professionals . Jones & Bartlett Publishers.
Purtilo, R. B., & Doherty, R. F. (2015). Ethical dimensions in the health professions . Elsevier Health Sciences.
