| Abstract|| |
A large component of philosophy consists of various approaches to the concept and implication of ethics. A philosophical study of moral issues of right and wrong is called ethics, and deals with the moral duties of the professional dental surgeons toward their patients, society or community and their colleagues. Ethical delivery of dental healthcare assumes greater relevance with the rapid advances in dental healthcare technologies and innovations in several areas of investigations and treatment. This article reviews the philosophy of ethics and ethical principles that the dental surgeon should follow.
Keywords: Ethics, Hippocratic oath, philosophy
|How to cite this article:|
Prasad D K, Hegde C, Jain A, Shetty M. Philosophy and principles of ethics: Its applications in dental practice. J Educ Ethics Dent 2011;1:2-6
|How to cite this URL:|
Prasad D K, Hegde C, Jain A, Shetty M. Philosophy and principles of ethics: Its applications in dental practice. J Educ Ethics Dent [serial online] 2011 [cited 2020 Jul 13];1:2-6. Available from: http://www.jeed.in/text.asp?2011/1/1/2/93408
| Introduction|| |
The ethics of any profession is self-inflicted and voluntarily accepted and not imposed by legislation. It is aimed at establishing and maintaining an honorable pattern of behavior recognized by members of the community. 
Since time immemorial, in the profession of dentistry, the code of ethics is outlined by the Hippocratic oath, which is a vow taken by professionals who are entitled or given an opportunity to practice. The Hippocratic Oath contains the Pythagorean duties of justice, secrecy, respect for teachers, and solidarity with peers.
The spectrum of ethical systems ranges from duty-oriented ethics to consequence-oriented ethics. The former is a static type of ethical system, which is based on religious concepts, whereas, the latter one is an evolutionary type of ethical system that is based on utilitarian thoughts. The utilitarian type of ethical system serves to be a better option for the development and advancement in the field of medical and dental science.
It is noteworthy that before the time of Hippocrates, the branch of medicine was based only on religious aspects. Therapeutic attempts were based on religious or magical beliefs and were commonly practiced by priests, spiritual healers, and witch-doctors. 
Dental ethics is an unwritten code, but there are certain guidelines that have been laid down for the information of the members of the profession. Dentistry, being one of the healing arts, has derived its code of behavior from the Hippocratic Oath.
The word 'ethics' is derived from the Greek word 'ethos' meaning custom or character. It is the philosophy of human conduct, a way of stating and evaluating principles by which problems of behavior can be solved. It is concerned with evaluation of human conduct and standards, and judging whether the actions are right or wrong.  Ethics is that branch of the discipline of philosophy that studies morality. It is the 'science' of the moral 
The question of ethics for dental surgeons should extend beyond a listing of right or wrong actions so that the dental association defines it as their code. In the late twentieth century, obvious changes have been observed regarding what is morally or ethically acceptable to the society; the dental professionals should equip themselves with the ability to cope with the change and maintain the highest ethical values.
When it comes to decision-making for the treatment aspect also, ethics play an important role. The relationship between a dentist and a patient may be based on three ethical models:
- Paternalistic model: In this type of ethical model, the dentist knows what is right for the patient and chooses the best treatment option for him without giving importance to what the patient desires. In other words, the dentist considers himself to be the father of the patient. This type of relationship totally neglects the patient's expectations, for example, if a dentist plans to close the diastema with a restoration, it might not be liked by the patient as he considers it to be a part of his identity.
- Engineering model: In this type of ethical model the health scientist is as detached as an objective scientist and leaves complete decision control to the patient. This type of relationship is also not favorable as it leaves no room for the dentist's decision and also the patient's expectations can be sometimes unrealistic, which cannot be met practically.
- Social contract model: This ethical model is based on genuine human interaction, on the grounds of humanism and friendship (philanthropy) in which both the dentist and the patient accept mutual obligations and rights. This is the most accepted and most favorable type of ethical model.
| Evolution and Philosophy of Ethics|| |
The original ethical concept was based upon mysticism. Tracing the history of ethics, it has been progressing gradually into the world of mystery, which speculates on the unknown. Subsequently, people started accumulating and recording knowledge based on their facts. In the history of Egypt and Babylonia, people were interested in their destiny and belief in life hereafter. The Egyptian 'Book of the Dead', dated 3500 B.C., describes immortality of the soul and lists many behaviors that were conducive to a desirable destiny. Prior to 1000 B.C., India produced the 'Vedas'. Among the expanded versions of the Vedas, were the Upanishads, which were remarkable for their discourses on many problems such as ethics, God, death, and immortality. ,
The founder of a philosophy with a scientific basis was the Athenian Epicurus (341-270 BCE). Asclepiades (124-40 BCE) of Bithynia is recognized as the first physician who was proficient in both philosophy and medicine. He was influenced by the teachings of the Epicurean philosopher Zeno of Sidon (in present-day Lebanon). 
During the middle ages, philosophy and religion were united together by a common ethical interest and there was a transformation of old concepts to the new one. Individuals were recognized as Christians and scientific discoveries sparked the revival of learning.
The Nineteenth Century was generally a time of equality and plenty for all, and the scientific theory became more pronounced during these years.
The Twentieth Century brought a great variety of moral beliefs, allowing a freedom in which each person could select his own values.
Johnson, in 1946, stated that philosophical approaches were better than a dualistic approach to ethics, which may provide dental professionals with the understanding to fashion a more eclectic approach to professional personal ethics.
Brinton, in 1950, stated that ethics was only a matter of two paths to follow and it was intensified by the fact that there was no provision for absolution of sins and an afterlife to cleanse the soul of its impurities so that the minor offenders could move on to heaven.
Durant, in 1954, stated in his book, 'The story of philosophy' that the ancient Greek philosophers Plato and Aristotle viewed ethics as a value to be strived fork, which was the basis of harmony in life and personal happiness.
Sabatier, in 1957, gave the either/or approach to ethics and morality remained intact.
According to B.F. Skinner, in 1971, ethics was a matter of performance discrepancy, devoid of personal values, and consisting mainly of activities that had to be learned by the management of the contingencies.
Nash, in 1984, stated that ethics was the key to expressing mutual respect among people and a normal and expected phenomenon for persons whose environment had enabled the ethical values to emerge and develop.
Bertolami, in 2004, identified three specific weaknesses in a typical ethics curriculum: 
- Failure to recognize that more education is not the answer to everything
- Ethics is boring
- Course content is qualitatively inadequate because it does not foster an introspective basis for true behavioral change.
A fourth element, an innovation, is directed to this third weakness and entails implementing a pre-curriculum very early in the dental educational experience, to address the disconnect between knowledge and action.
In an answer to this, Jenson, in 2004, did not agree to statements given by Bertolami and stated that Bertolami's article stimulated discussion on what exactly we needed to do to help students and colleagues make the right decisions, when they otherwise would not, even though they knew better. 
With this background, Johnson stated that people tend to search for external guidelines for the right conduct and spend a good deal of energy identifying to whom they should report their behavior.
| Codes of Professional Ethics|| |
The purpose of these codes is to achieve a high level of ethical consciousness, decision-making, and practice by the members of the profession. These codes are as follows: 
- Increasing ethical and professional consciousness and the sense of ethical responsibility
- Recognition of ethical issues by the members and making a more informed ethical decision
- Establishing a standard for professional judgment and conduct
- Provide a statement of the ethical behavior that the public can expect from the members
| Ethical Principles|| |
Moral conduct and judgment are dealt with in the philosophy of ethics. There are several principles that dental professionals must be aware of in their clinical practice. The major principles are: 
- To do no harm (non-maleficence)
- To do good (beneficence)
- Respect for persons
- Veracity or truthfulness
| Duties and Obligations of the Dental Surgeon|| |
The first principle of medicine enunciated in the Hippocratic Oath is that the doctor's first duty is toward his or her patients. The major ethical principles that can guide in the performance of these duties are as follows:
- To do no harm (non-maleficence): To do no harm or non-maleficence is generally attributed to Hippocrates. It is the main foundation of social morality. The dental care professionals support this principle, but sometimes they feel guilty of transgressions that go beyond a limitation by breaking a rule or law. Iatrogenic disease is the term given for the illnesses caused by doctor to the patient whether knowingly or unknowingly.
This is the first macro-ethical principle and the investigator has the responsibility to not harm individual subjects as well as the whole population, in the population-based research studies.
- To do good (beneficence): To do good, or beneficence also traced to Hippocrates, is required for all dental care providers. The role of dental surgeons and dental hygienists should be to benefit patients, as also not to inflict harm. The expectation of the patient is that the care provider will initiate beneficial action and that there is an agreement between the dental surgeon and the patient that some good will result. Therefore, attempts should be made to maximize the benefits and minimize the harm.
- Respect for persons: Respect for persons incorporates mainly two ethical principles such as autonomy and informed consent. Autonomy dictates that healthcare professionals respect the patient's capacity for self-determination in making decisions concerning their treatment, and informed consent is an essential component of a patient's right to autonomy.
- Justice: The primary duty of the dental professional is to serve the patients irrespective of class, creed, and so on. Justice demands that each person be treated equally. The principle of justice calls for an obligation to protect the weak and to ensure equity in rights and benefits, both for groups and for individuals.
- Truthfulness or veracity: The patient-doctor relationship is based on trust. Lying shows disrespect to the patient and threatens the relationship. The dental surgeon may feel that the patient should take some action and manipulates the information given to him. Whatever the reason, ultimately the relationship will suffer and the dental surgeon will be guilty of transgressing this principle. 
- Confidentiality: Confidentiality is a principle that can be traced to the Hippocratic Oath and exists today in the International Code of Medical Ethics, the principles of ethics of the American Dental Association (ADA), American Dental Hygienists' Association (ADHA), and the American Dental Assistants Association. Patients have the right to expect that all communications and records pertaining to their care will be treated as confidential. Dental surgeons should respect the confidentiality of client information.
Toward profession/professional colleagues
The dental surgeon has to remember that the treatment and cure of the disease depends on the skill and prompt attention showed to the patient. The dentist has to be sober, courteous, sympathetic, helpful, modest, and punctual.
Dental surgeons should conduct professional activities and programs and should develop relationships with their colleagues honestly, respectfully, and with full responsibility. They should encourage a work environment that minimizes risk to their personal health and that of their colleagues, and promotes individual professional growth and development. 
Towards the society
Dental surgeons should assume leadership in the community and should recognize and uphold the laws and regulations governing their profession. They should participate in the dental health education of the public by promoting measures that improve the dental health of both the individual and the community.
The aspects mentioned in the Hippocratic oath should always be kept in mind by the dental professionals so as to fulfill the duties and obligations toward the patient, profession, and the society. 
- Practicing the profession with a conscience and dignity
- Patient's health should be given first priority
- Secrets have to be respected, which are confined
- Respect should be given to the teachers, with gratitude
- Colleagues should be considered as brothers or sisters
- No consideration should be given to religion, nationality, race, party politics or social standings
- Surrender life for the service of humanity
- Maintain utmost respect for human life
Research on dental profession should be encouraged and while conducting researches on human subjects, the ethical principles have to be followed with due respect. The primary purpose of dental research involving human subjects is to understand the causes, development, and effects of the diseases and to improve the preventive, diagnostic, and therapeutic interventions. Investigators should promote respect for all human subjects and their health and rights, and should consider the ethical, legal, and regulatory norms and standards for research involving human subjects in their own countries, as also the applicable international norms and standards.
| Discussion|| |
The American Dental Association has put forward the statement that constitutes the 'Principles of Ethics and Code of Professional Conduct'. The purpose is to uphold and strengthen the dental profession as a member of the learned profession. 
The National Board for Certification (NBC) believes that the guidelines stated in the ethical standards are fair and reasonable and represent the desirable code of professional conduct for dental technology.
Practicing dental surgeons assume the obligation of maintaining and enriching the profession. Each and every member shall choose to meet this obligation according to the dictates of his/her personal conscience. This is based on the needs of the general public that the professional dental surgeons have committed to serve.
There exists a need to teach professional ethics in dentistry and the appropriate goals for teaching professional ethics have been identified: 
- To sensitize student dentists to the moral dimensions of professional life and practice
- To develop in student dentists, the skills of ethical analysis
- To foster in student dentists respect for disagreement and toleration of ambiguity
- To assist student dentists in explicating the moral responsibilities incurred in becoming a member of the profession of dentistry
- To motivate the student dentists' continued learning in the field of professional ethics
'Ethical imperialism' is the term for imposing the values and priorities of rich countries on the developing world. Countries differ in the level of material progress and even within each country there may be people of different cultures, although cultural values and social mores must be respected, our aims and objectives of the studies should be to stimulate change in certain customs or constitutional behavior, so as to deal effectively with risks to health, which often require advocacy. It is possible to be an advocate and at the same time preserve sound scientific judgment and ethical values.
Individual dentists and organized dentistry alike invariably claim to be (members of) a profession. This label is cherished because it suggests a special social, moral, and political status. An occupation cannot simply claim professional status. That status must be granted by the public. 
Dentistry qualifies as a profession, but that is also exhibiting a trend toward once again becoming a business (as it was before the nineteenth century). For the sake of honesty with the public, dentistry must make a choice between these two models. 
Professional etiquette refers to the way dentists relate to one another and is governed by the ADA Code of Professional Conduct, which expresses specific types of conduct that are either required or prohibited. Sometimes, ethics and etiquette may be in conflict. The problem of financial issues that conflict with ethical ones is discussed along with the problem of commercialism, in the practice of dentistry. Debts from dental school may adversely affect the professional behavior of young dentists, while general dentists might succumb to 'goodies' provided by specialists. These often include continuing education courses, gifts, trips, and kickbacks. Specialists may fail to inform the patients of the improper or poor quality of treatment by the referring general practitioner, fearing loss of referrals. These problems require fixing for the future of ethical dental practice. 
| Conclusion|| |
The dental profession and the individual dental surgeons have a duty to recognize the reciprocity of the relationship that exists with society, and the duty of covenantal fidelity. The dental surgeon has a duty to conduct his or her professional life in accordance with the ethical principles rooted in the moral rules and to maintain his or her level of knowledge and skill current. These are the principles of beneficence, autonomy, and justice, in both individual and societal contexts. The dental surgeon has an obligation to participate in the professional community to help ensure distribution of society's resources and to share the burden of professional self-regulation, just to the extent that such a privilege is granted by society. The current Principles and Code are helpful expressions of dentistry's professional obligations, but are deficient in not speaking about the reciprocity of the relationship, the principle of self-determination, and not providing for societal participation in the covenant agreement.
| References|| |
|1.||Seear J. Law and Ethics in Dentistry. 2 nd Ed. Great Britain: Wright and Sons, Ltd; 1981. |
|2.||Yapijakis C. Hippocrates of Kos, the father of clinical medicine, and asclepiades of bithynia, the father of molecular medicine. In vivo 2009;23:507-14. |
|3.||Peter S. Essentials of preventive and community dentistry. New Delhi: Arya (Medi) Publishing House; 2 nd ed. 2005. |
|4.||Woodal L, Irene R. Legal, Ethical and management aspects of the dental care System. 3 rd ed. St. Louis, Mosby-Year Book; 1987. |
|5.||Bertolami CN. Why our ethics curricula dont work. J Dent Educ 2004;68:414-25. |
|6.||Jenson LE. Why our ethics curricula do work. J Dent Educ 2005;69:225-8. |
|7.||Davison JA. Legal and ethical considerations for dental hygienists and assistants. St. Louis: Mosby, Inc.; 2000. |
|8.||Nash DA. On ethics in the profession of dentistry and dental education. Eur J Dent Educ 2007;11:64-74. |
|9.||Welie JV. Is dentistry a profession? Part 1. Professionalism defined. J Can Dent Assoc 2004;70:529-32. |
|10.||Welie JV. Is Dentistry a profession? Part 3. Future challenges. J Can Dent Assoc 2004;70:675-8. |
|11.||Newbrun E. Professional ethics and professional etiquette in dentistry: Are they compatible? J Hist Denty 2007;55:119-25. |
D Krishna Prasad
Department of Prosthodontics and Crown and Bridge, A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka - 575 018
Source of Support: None, Conflict of Interest: None