Ethics in Dental Hygiene Practice

Core Review

The Six Core Ethical Principles

Ethical principles provide the foundation for professional behavior. The NBDHE expects you to recognize each principle and apply it to clinical situations:

1. Autonomy (Self-Determination)

• Definition: The right of competent individuals to make their own informed decisions about their healthcare. The clinician respects the patient's values, preferences, and choices — even when they differ from the clinician's recommendations.
• Clinical application:
  • Obtaining informed consent before treatment
  • Respecting a patient's decision to refuse recommended treatment (informed refusal)
  • Respecting cultural, religious, and personal values that influence healthcare decisions
  • Not imposing the clinician's values on the patient
• Ethical challenge: What if the patient refuses treatment that the clinician believes is essential? (e.g., a patient with Stage IV periodontitis refuses SRD). The clinician's duty is to inform, educate, and respect the decision — while thoroughly documenting the informed refusal.
• Violation: Treating a patient without their consent, coercing a patient into treatment, dismissing a patient's stated preferences.

2. Beneficence (Doing Good)

• Definition: The duty to act in the best interest of the patient — to promote good and prevent harm. The clinician actively seeks to benefit the patient.
• Clinical application:
  • Providing the highest standard of care
  • Recommending preventive therapies (fluoride, sealants) to prevent future disease
  • Referring to specialists when the patient's needs exceed the clinician's competence
  • Engaging in continuing education to maintain and improve clinical skills
  • Identifying and addressing systemic health issues that manifest orally
• Ethical challenge: Balancing beneficence with autonomy. The clinician may believe a treatment is in the patient's best interest, but the patient has the right to refuse.
• Violation: Providing substandard care, failing to refer when indicated, practicing outside one's scope of competence.

3. Nonmaleficence (Do No Harm)

• Definition: The duty to avoid causing harm to the patient. This is the most fundamental ethical principle in healthcare, rooted in the Hippocratic Oath: "First, do no harm."
• Clinical application:
  • Maintaining current infection control standards
  • Using appropriate radiation safety measures
  • Avoiding unnecessary or excessive treatment (overtreatment can cause harm)
  • Recognizing personal limitations and referring when needed
  • Ensuring proper instrument sterilization
  • Monitoring for medical emergencies and being prepared to respond
• Ethical challenge: Treatments that benefit the patient may also cause some degree of harm (e.g., SRD causes post-treatment sensitivity). The ethical calculation is whether the benefit outweighs the harm.
• Violation: Practicing while impaired (substance use, illness, fatigue), using unsterilized instruments, performing procedures without adequate training.

4. Justice (Fairness)

• Definition: The fair, equitable, and appropriate distribution of healthcare resources and treatment. All patients should receive care without discrimination.
• Clinical application:
  • Treating all patients equally regardless of race, ethnicity, religion, gender, sexual orientation, socioeconomic status, or disability
  • Not discriminating against patients with infectious diseases (HIV, hepatitis)
  • Allocating appointment time fairly (not giving preferential treatment based on ability to pay)
  • Advocating for access to care for underserved populations
  • Charging fair and consistent fees
• Ethical challenge: Limited resources (time, materials, access). How does the clinician prioritize care when resources are constrained?
• Violation: Refusing to treat a patient based on HIV status (illegal under the ADA and unethical), charging different fees for the same service based on insurance status (may be illegal depending on contractual arrangements), providing substandard care to Medicaid patients.

5. Veracity (Truthfulness)

• Definition: The duty to be honest and truthful with patients, colleagues, and the public. Trust is the foundation of the clinician-patient relationship.
• Clinical application:
  • Providing accurate information about diagnosis, prognosis, and treatment options
  • Disclosing errors or adverse events honestly
  • Not exaggerating treatment needs or promising unrealistic outcomes
  • Accurate documentation (not falsifying records)
  • Honest billing practices
  • Providing truthful information in professional communications and advertising
• Ethical challenge: Delivering bad news. The clinician must balance truthfulness with compassion and sensitivity.
• Violation: Misrepresenting treatment needs for financial gain (fraud), falsifying patient records, covering up errors, misleading advertising.

6. Confidentiality

• Definition: The duty to protect patient information and not disclose it without the patient's consent. Rooted in respect for autonomy and privacy.
• Clinical application:
  • HIPAA compliance (see HIPAA module)
  • Not discussing patient information in public areas (elevators, hallways, break rooms)
  • Securing patient records (both paper and electronic)
  • Obtaining patient consent before sharing information with family members, other providers, or third-party payers
  • Maintaining professional boundaries on social media (never post patient information or images without explicit consent)
• Ethical challenge: Mandatory reporting (e.g., suspected child abuse, certain infectious diseases). The clinician's duty to report overrides confidentiality in specific legal circumstances.
• Violation: Discussing patients by name in public, posting patient information on social media, accessing records of patients not under one's care without authorization, sharing patient information with unauthorized individuals.

Ethical Decision-Making Framework

When faced with an ethical dilemma, use a structured approach:

1. Identify the ethical issue: What principle(s) are in tension? (e.g., autonomy vs. beneficence — the patient refuses recommended treatment)

1. Gather relevant information: What are the clinical facts? What does the patient value? What are the legal and professional standards?

1. Identify the stakeholders: Who is affected by the decision? (patient, family, other providers, practice)

1. Consider your options: What are the possible courses of action? What are the likely consequences of each?

1. Apply ethical principles: Which option best respects autonomy? Promotes beneficence? Avoids nonmaleficence? Upholds justice? Honors veracity? Protects confidentiality?

1. Consult resources: ADHA Code of Ethics, ADA Principles of Ethics, state dental practice act, colleagues, ethics committees

1. Make a decision and act: Implement the chosen course of action

1. Evaluate and reflect: What was the outcome? What could have been done differently?

ADHA Code of Ethics

The ADHA Code of Ethics provides specific guidance for dental hygienists. Key provisions include:

• Duty to the patient: Provide the highest quality care, respect autonomy, maintain confidentiality, obtain informed consent
• Duty to the profession: Maintain competence through continuing education, uphold the reputation of the profession, report unethical conduct by colleagues
• Duty to society: Promote access to care, participate in community service, advocate for public health measures (water fluoridation, tobacco cessation)
• Duty to self: Maintain personal health and well-being, practice within scope of competence, pursue lifelong learning

Common Ethical Scenarios

Scenario 1: The Non-Compliant Patient A patient with Stage III periodontitis repeatedly fails to improve home care despite extensive education. Probing depths are worsening. The patient says they "don't have time" for flossing.

Ethical analysis: Autonomy (patient chooses not to improve home care) vs. Beneficence (clinician wants to prevent disease progression). The ethical approach is to continue educating, respect the patient's autonomy, document thoroughly, and consider whether the patient might benefit from a different approach (powered brush, interdental brushes, motivational interviewing).

Scenario 2: The Impaired Colleague A dental hygienist colleague appears to be under the influence of alcohol or drugs at work. You notice slurred speech, unsteady gait, and the smell of alcohol.

Ethical analysis: Nonmaleficence (an impaired clinician puts patients at risk of harm) overrides loyalty to a colleague. The ethical (and legal) duty is to report the concern to the employer/supervisor. The state dental board and/or professional assistance program may also need to be contacted. Protecting patients is the primary duty.

Scenario 3: Overtreatment A dentist in the practice routinely diagnoses "periodontal disease" in patients who have minimal pocketing and no bone loss, recommending quadrant SRD for what appears to be gingivitis.

Ethical analysis: Veracity (the dentist may be misrepresenting diagnoses for financial gain) and Nonmaleficence (overtreatment causes unnecessary harm — cost, discomfort, potential attachment loss from unnecessary instrumentation). The ethical approach may involve discussing concerns with the dentist directly, and if unresolved, reporting to the appropriate authority (state dental board).

Scenario 4: Social Media and Confidentiality A dental hygienist posts a photo on Instagram of a "crazy calculus bridge" they removed, with the caption "You should see what this patient's mouth looked like!" The patient's face is not shown, but the post includes the practice location.

Ethical analysis: This is a HIPAA violation and an ethical breach of confidentiality. Even without the patient's face, the practice location and details could potentially identify the patient. Never post patient information (including de-identified clinical photos) on personal social media without explicit, documented patient consent.

Clinical Application

A 72-year-old patient with mild dementia presents with extensive caries and periodontitis. The patient's daughter (durable power of attorney for healthcare) insists on "doing everything possible — fill every tooth, deep clean everything." However, the patient becomes extremely agitated during dental procedures and repeatedly says, "I want to go home, please stop." You assess that the patient lacks capacity for complex treatment decisions but can clearly communicate distress.

Ethical issues:

• Autonomy: Even a patient with diminished capacity has the right to have their distress and refusal respected
• Beneficence: The daughter wants aggressive treatment, but is it truly in the patient's best interest given the distress it causes?
• Nonmaleficence: Forcing treatment on a distressed, unwilling patient causes psychological (and potentially physical) harm

Approach:

1. Discuss with the daughter: the patient's distress is real and ethically significant
2. Propose palliative/preventive approach: manage pain and infection, prioritize preventive care, minimize interventions that cause distress
3. Consider sedation options if appropriate for specific essential treatments
4. Document the ethical deliberation and the agreed-upon plan

Common Traps

• TRAP: Confusing ethical and legal standards. Something can be legal but unethical (e.g., over-treatment that is legally within scope of practice but not clinically indicated), or ethical but illegal (rare, but civil disobedience for moral reasons).
• TRAP: Assuming benevolence justifies overriding autonomy. "I know what is best for you" does not give the clinician the right to treat without consent.
• TRAP: Thinking confidentiality is absolute. There are exceptions: mandatory reporting (child abuse, elder abuse), imminent danger to self or others, and certain infectious disease reporting.
• TRAP: Failing to report an impaired colleague out of loyalty. Patient safety takes precedence.