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 Third Edition

Ethics, Jurisprudence,
& Practice Management
in Dental Hygiene
Vickie J. Kimbrough-Walls, RDH, MBA
Charla J. Lautar, RDH, PhD

Pearson
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reserved. Printed in the United States of America. This publication is protected by Copyright and permission should be
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sion(s), write to: Rights and Permissions Department.

Notice:
The authors and the publisher of this volume have taken care that the information and technical recommendations con-
tained herein are based on research and expert consultation and are accurate and compatible with the standards gener-
ally accepted at the time of publication. Nevertheless, as new information becomes available, changes in clinical and
technical practices become necessary. The reader is advised to carefully consult manufacturers’ instructions and infor-
mation material for all supplies and equipment before use and to consult with a health care professional as necessary.
This advice is especially important when using new supplies or equipment for clinical purposes. The authors and pub-
lisher disclaim all responsibility for any liability, loss, injury, or damage incurred as a consequence, directly or indi-
rectly, of the use and application of any of the contents of this volume.

Library of Congress Cataloging-in-Publication Data

Kimbrough-Walls, Vickie J.
Ethics, jurisprudence & practice management in dental hygiene / Vickie
J. Kimbrough-Walls, Charla J. Lautar.—3rd ed.
p. ; cm.
Other title: Ethics, jurisprudence, and practice management in dental hygiene
Includes bibliographical references and index.
ISBN-13: 978-0-13-139492-6
ISBN-10: 0-13-139492-4
1. Dental hygiene—Practice. 2. Dental ethics. 3. Dental
jurisprudence. I. Lautar, Charla J., 1949- II. Title. III. Title:
Ethics, jurisprudence, and practice management in dental hygiene.
[DNLM: 1. Practice Management, Dental—organization & administration.
2. Dental Hygienists. 3. Ethics, Dental. 4. Legislation, Dental. WU 77]
RK60.5.K563 2012
174’.96176—dc22 2010037346

10 9 8 7 6 5 4 3

ISBN-10: 0-13-139492-4
ISBN-13: 978-0-13-139492-6
 CONTENTS

Preface xi
Acknowledgments xv
Reviewers xvii

Chapter 1 Introduction to Moral Philosophy and Moral Reasoning 1

Objectives 1
Key Terms 1
Introduction 1
Case Study 2
Ethical Theories: Duties and Consequences 2
Ethics 2
Normative Ethics 2
Ethical Theories: A Survey of Moral Theories 3
Utilitarianism 3
Kantian Ethics 6
Virtue Ethics 7
Social Philosophy 8
Utilitarianism and Justice 8
Liberalism and Rights 9
Three Facts about Rights 9
Rawls’s Theory of Justice 11
Applying Rawls’s Theory to Health Care Problems 13
Summary 14
Critical Thinking 14

Chapter 2 Core Values and Additional Ethical Principles 16

Objectives 16
Key Terms 16
Introduction 16
Case Study 17
Core Values 17
Autonomy 18
Confidentiality 19
Health Insurance Portability and Accountability Act 20
Societal Trust 23
Nonmaleficence 24
Beneficence 24
iii
iv Contents

Justice 25
Veracity 25
Additional Ethical Principles 26
Fidelity 26
Parentalism/Paternalism 26
Utility 27
Summary 29
Critical Thinking 29

Chapter 3 Informed Consent 30

Objectives 30
Key Terms 30
Introduction 30
Case Study 30
Historical Background 31
Giving Information 31
Giving Consent 32
Rights and Duties Involved in Informed Consent 32
Evolution of the Concept of Informed Consent 33
Types of Consent 33
Harm-avoidance Model 34
Examples 34
Autonomy-enhancing Model 35
Exceptions to the Rule 35
The Ideal Context 38
Disclosure in the Office: Practical Hints 39
Informed Consent and Research 42
Use of Photos and Other Recording Devices 43
Disclosure by Infected Health Care Providers 44
Patients’ Bill of Rights 46
Summary 47
Critical Thinking 47

Chapter 4 Decision Making 49

Objectives 49
Key Terms 49
Introduction 49
Case Study 50
Ethical Dilemma 50
Examples 52
 Contents v

Solving Ethical Problems 53

Kohlberg’s Model 53
Rest’s Model 54
Decision-Making Process 55
Applying Decision-Making Steps 57
Identify the Problem 57
Gather the Facts 57
List the Alternatives 58
Select the Course of Action 59
Act on the Decision 59
Evaluate the Action 60
Summary 61
Critical Thinking 61

Chapter 5 Jurisprudence 62
Objectives 62
Key Terms 62
Introduction 63
Case Study 63
Criminal Law 63
Insurance Fraud 64
Civil Law 65
Tort Law 66
Professional Negligence and Malpractice 66
Assault and Battery 69
Defamation 69
Contract Law 70
Abandonment 72
Risk Management 73
Case Law 75
Licensure 75
Educational Requirements 75
Written Board Exams 76
Practical Board Exams 76
Other Requirements for Licensure 77
Credentialing 78
Certification 78
Practice Act 78
Protection 79
vi Contents

Regulation 79
Scope of Practice 81
Supervision 81
Forensic Dentistry 84
Summary 85
Critical Thinking 85

Chapter 6 Social Issues 86

Objectives 86
Key Terms 86
Introduction 86
Case Study 87
Workplace Legislation 87
Affirmative Action 87
Pregnancy Discrimination Act 88
Family and Medical Leave Act 88
Americans with Disabilities Act 89
Age Discrimination in Employment Act 90
Sexual Harassment 90
Occupational Safety and Health Act 91
Reporting Domestic Violence 92
Child Abuse 93
Spouse Abuse 95
Elderly Abuse 96
Access to Care 97
Disparities 97
Financial Barriers 99
Managed Care 100
Government Assistance 101
Geographical and Organizational Barriers 102
Sociological and Cultural Barriers 104
Justice 106
Advocacy 107
Summary 109
Critical Thinking 109

Chapter 7 Aspects of Practice Management 110

Objectives 110
Key Terms 110
Introduction 110
Case Study 111
 Contents vii

Management Consultants 111

Consumer-Influenced Changes 111
The Focus for Consulting Firms 112
Customize Business Systems 112
Business and Dental Hygiene 113
Employer Management Styles 113
The Team Concept 114
Team Communication 114
Defining Staff Roles 115
Cross Training 116
Staff Meeting Benefits 116
Meeting Activities 116
Expectations and Public Relations 117
Employers’ Expectations 117
Interpersonal Skills 118
Communicate Your Education 119
Your Expectations 119
Staff Expectations 120
Patient Expectations 120
Marketing and the Dental Practice 121
Using Expertise to Market the
Practice 121
Successful Marketing 122
Using Advertising 122
Marketing the Patient’s Health
Care 123
Marketing the Practice 123
Marketing Yourself 124
Marketing Strategies 124
Marketing and Profit Centers 125
Profit Center and Patient Compliance 125
Profit Center Options 125
Other Practice Considerations 126
Summary 127
Critical Thinking 127

Chapter 8 The Business of Dental Hygiene 129

Objectives 129
Key Terms 129
viii Preface

Introduction 129
Case Study 130
Dental Hygiene Assessment 130
Thorough Patient Assessment 131
Building and Perfecting Skills 131
Preventative Home Care 132
Maximizing Skills 132
Developing Leadership Qualities 133
The Business of Dental Hygiene 135
Overhead Cost 135
Creating Daily Schedules 136
Dental Insurance and Hygiene Services 137
Common Insurance Plans 138
Insurance Billing Procedures 139
Insurance Codes 139
Excluded Treatments 139
Continuing Care and Recare Systems 141
Continuing Care Systems 141
Continuing Care Objectives 142
Time Management 143
Working with Other Dental Hygienists 144
Working as a Public Health Dental Hygienist 144
Career Alternatives 145
Six Roles of the Dental Hygienist 145
Lifelong Learning 146
Summary 146
Critical Thinking 147

Chapter 9 Alternate Practice Models: Future Trends

for Oral Health Care 148
Objectives 148
Key Terms 148
Introduction 148
Case Study 149
Overview of Alternate Practice in the United States 149
Alternate Practice Models 152
International Models for the Dental Therapist 152
Dental Therapists in the United States 154
Minnesota—Advanced Dental Therapist 154
 Contents ix

Dental Therapist 155

Alaska—Dental Health Aide Therapists 155
Current Alternative Practice Models in the
United States 157
California 157
Colorado—Unsupervised Practice 161
Maine—Unsupervised Practice 161
New Mexico—Collaborative Practice 162
Summary 162
Critical Thinking 163

Chapter 10 Seeking the Dental Hygiene Position 164

Objectives 164
Key Terms 164
Introduction 164
Case Study 165
Beginning the Search 165
Keeping Options Open 166
Working as a Temporary 166
Employment Resources 167
Preparing for Interviews 167
Interview Skills 167
The Employer’s Interview 169
Common Interview Questions 169
Your Interview 170
The Working Interview 171
Interviews and Personality Tests 172
Attire 172
Leadership versus Management: Qualities and
Opportunities 174
Résumés 174
Perfecting Your Resume 175
The Cover Letter 176
Post-Interview Acknowledgments 178
Beginning the New Job 179
Compensation 179
Benefits 181
Major Benefit Components 181
Negotiating 182
x Contents

Other Negotiating Considerations 182

Employment Contracts 184
Policy Manuals 184
Employee Evaluations 184
Summary 185
Critical Thinking 186

Chapter 11 Planning for the Future and Career Longevity 187

Objectives 187
Key Terms 187
Introduction 187
Case Study 188
The Basics of Investing 188
Investment Vehicles 189
Earned Interest 191
Investment Brokers 191
Spend Money Wisely 191
Insurance Coverage for Dental Hygienists 192
Liability Coverage 192
Disability Coverage Disability 192
Life Insurance Coverage 193
Term or Whole-Life Policies 193
Professional Membership 194
Patient Perspective 194
Self-Care 194
Cumulative Trauma Disorders 194
Dental Operatories 196
Healthy Lifestyle 196
Therapeutic Considerations 196
Summary 197
Critical Thinking 198

Appendix A Internet Resources 199

Glossary 201
Works Cited 205
Index 213
 PREFACE

The practice of dental hygiene continues to evolve in both scope of duties and changes in legis-
lation. New workforce models are currently being offered for those interested in alternative set-
tings and flexibility for providing oral health care to those with limited or no access to a dental
office. Additionally, more health care providers are being sought in the profession of forensics in
the event of catastrophes.
The information and examples in this book are designed to orient dental hygiene students
to clinical practice and its many applications in an office setting. Although dental practices and
dental hygiene procedures can be generalized, each office will be unique in its daily operations
and policies. As public health is woven through the various roles of the dental hygienist, this
book contains limited discussions regarding public health issues; however, it is not intended to
replace the community health textbook you are presently using.

ORGANIZATION OF THE TEXT

Ethics, Jurisprudence, & Practice Management in Dental Hygiene is organized into 11 chapters
and divided into two major sections: ethics and jurisprudence, and practice management as it
applies to the dental hygienist as an employee and potential independent practitioner. The first
two chapters introduce codes of ethics and discuss ethical principles, moral values, and how each
influences society, individual, and the profession. Chapters 3 and 4 present informed consent and
decision making as they relate to patients and the practioner, and Chapters 5 and 6 discuss legal
information and social issues where the dental hygienist should be knowledgable, and as they
may be applied to patient care.
The second half of the text will cover practice management. Chapters 7 and 8 introduce
you to the dental practice and how it must operate as a small business. Chapter 9 is new and
presents current information on workforce models such as the dental therapist and the regis-
tered dental hygienist in alternative practice. Chapters 10 and 11 provide information on inter-
viewing, seeking your first dental hygiene position, and planning for a long-term career in
your new profession.
At the end of the book are listed references, key terms in a glossary, and Internet resources.
Throughout the book are boxes that highlight and condense information that was previously dis-
cussed. Follow-ups and critical-thinking questions integrate the chapter’s content with the chap-
ter’s case study.

Chapter Format
Each chapter is consistent in its presentation of information and includes the following:
Objectives are statements designed to inform the student about the overall knowledge
gained from chapter information.
Key Terms are listed at the beginning of each chapter and you will find them bolded and
italicized in the text as you read through the chapter. They emphasize important concepts
or major points of chapter content. These terms are also found at the end of the book in the
glossary.
xi
xii Preface

Case Studies The case studies present short scenarios that introduce and highlight chapter
content. Some include a task or ask you to consider applying the chapter to the case in
order to better understand how it applies to you as a dental hygiene professional.
Critical Thinking questions are found at the end of each chapter. These questions help
you to insure your knowledge of the chapter content is correct, and some can be used for
classroom discussion.

SPECIAL FEATURES
This third edition includes information regarding the practice of dental hygiene in Canada
and internationally. Canadian dental hygienists are similar to American dental hygienists in
many ways but differ in that the majority of them practice under self-regulation. In this global
economy and transient society, it is important to be prepared for the opportunities of one’s
profession.
Also new to this edition is information on the new workforce models being offered and
developed in the United States such as dental therapists, the registered dental hygienist in alter-
native practice, collaborative practice, and most recently, unsupervised practice in Maine.
Aspects of practice management have expanded to include production goal setting, more busi-
ness planning for dental hygiene, and identifying characteristics for leadership skills. You will
find additional case studies located on MyHealthProfessionsKit along with many more resources
designed to prepare you for entering the dental hygiene profession.

TEACHING AND LEARNING PACKAGE

Ethics, Jurisprudence, & Practice Management in Dental Hygiene has been written with the stu-
dent in mind. Each chapter provides background information so that students without previous
dental experience can better relate to topics in the text and apply them to clinical experiences
they may have had during their dental hygiene education. The content provided in the text will
enhance the development of professionalism students learn as they interact with peers and
patients through a broad spectrum of topics for discussion and application to real situations.

For the Student

As a student, you will find the case studies in each chapter essential to better comprehension of
the chapter content and how it applies to the practice of dental hygiene upon graduation. The
MyHealthProfessionsKit includes more case studies related to ethical decision making along
with Internet resources and business plan templates that may be required for assignments. For
additional information please go to www.myhealthprofessionskit.com.

For the Instructor

Ethics, Jurisprudence, & Practice Management in Dental Hygiene now includes updated infor-
mation on the new workforce models for oral health care professionals: dental therapists,
advanced dental therapists, the Alaskan model (DHAT), and more. Additionally, new case stud-
ies are found in this edition and the previous case studies can be found on the
MyHealthProfessionsKit website. This third edition has updated PowerPoint presentations that
can be enhanced to customize your own lecture style and content, along with test bank questions
 Preface xiii

to include on quizzes or tests. There is also a teaching tip component that offers suggestions
for classroom activities and assignments. For additional information, please go to www.
myhealthprofessionskit.com.

STUDY TIPS FOR STUDENTS

Many dental hygiene students use multiple methods for learning course content. The use of tech-
nology provides unlimited resources for gathering data and more examples to enhance student
learning. The MyHealthProfessionsKit website provided for you with this text is one more way
technology may assist in your overall understanding of the material and how it applies to the den-
tal hygienist.
As you read and participate in the critical-thinking exercises, keep in mind that experiences
will be unique. In this new millennium, the art and science of dental hygiene continue to progress
and evolve. Consider the following as they apply to the content of each chapter:
✓ Supervision laws have been relaxed that allow for increase access to care and help elimi-
nate disparities among diverse and underserved population groups.
✓ Strategies are being developed to increase cultural competencies and multidisciplinary
collaboration as well as to increase the number of minorities in the oral health workforce.
✓ Dental hygienists are using more of their skills as oral health is becoming an important
entity of general health.
✓ Dental hygienists are becoming more responsible for the regulation of their profession.
As a student, actively discuss dental situations you have previously experienced in your
dental hygiene education. On becoming a registered or licensed dental hygienist, you are encour-
aged to actively participate in furthering the development of patient education and dental hygiene
research as well as your own education. Reach out to communities that are not able to access
dental care in a traditional setting and continually stay abreast of the link between periodontal
disease and total body health, as patients see the dental hygienist as the oral health care special-
ist. The knowledge and relationships that build from networking with other professionals will be
invaluable.
We hope that you find personal and professional satisfaction in your dental hygiene career
and as a member of the dental hygiene profession. As dental hygienists move outside the isolated
private dental office and globalism facilitates the exchange of information and culture, embrace
dental hygiene wherever your future may be.
This page intentionally left blank
 ACKNOWLEDGMENTS

To my sons, Kris, Lenny, and Rik—you continue to become my best friends and appreciate my
pursuits in higher education, my mom Joanne, for her continuous pride in my achievements, and
my, husband Mick—thank you for understanding my responsibilities and being patient as I jug-
gle all these balls in the air.
I appreciate the many educators I have been in contact with during my career and respect
the collaborative efforts to advance dental hygiene in all aspects of its potential. Special thanks to
my fellow faculty at Truckee Meadows Community College for having open minds and the will-
ingness to try new ideas that contribute to our positive learning environment and continued
achievements.
Vickie J. Kimbrough-Walls, RDH, MBA

Thank you to Dr. Mohamed Elsamahi for his support and advice throughout the writing of the
third edition. I would also like to thank those individuals and fellow dental hygienists who con-
tributed case studies for this text and previous editions, including the Instructor’s Manual, which
are now on the website MyHealthProfessionsKit. In particular, I would like to recognize Teri
McSherry for her case study in chapter four and to thank fellow dental hygiene educators Debbie
Boyke and Judi Thomas for their prewriting encouragement with this edition.
Charla J. Lautar, RDH, PhD

xv
This page intentionally left blank
 REVIEWERS

Third Edition Reviewers Robin B. Matloff, RDH, BSDH, JD

Marsha Bower, RDH, CDA, MA Mount Ida College
Monroe Community College Newton, Massachusetts
Rochester, New York
Shelly A. Purtell, RDH, MA
Amy E. Cooper, RDH, BA Broome Community College
Tarrant County College Binghamton, New York
Hurst, Texas
Salim Rayman, RDH, BS, MPA
Renee Cornett, RDH, MBA Hostos Community College
Austin Community College Bronx, New York
Austin, Texas
Maribeth Stitt, RDH, MEd
Laura Cunningham, MEd Lone Star College—Kingwood
University of Oklahoma Kingwood, Texas
Oklahoma City, Oklahoma
Sharon Struminger, RDH, MPS, MA
Ann Curtis, RD, RDH, MS, CAS Farmingdale State College
University of Maine at Augusta Farmingdale, New York
Bangor, Maine
Rebecca G. Tabor, RDH, MEd
Jacquelyn L. Fried, RDH, MS Western Kentucky University
University of Maryland Dental School Bowling Green, Kentucky
Baltimore, Maryland

Tracy Gift RDH, MS

Mohave Community College
Bullhead City, Arizona

xvii
xviii Reviewers

Previous Edition Reviewers David C. Reff, DDS

Doni L Bird, RDH, MS Apollo College
Santa Rosa Junior College Boise, Idaho
Santa Rosa, California
Bonnie Tollinger, CDA
Ann Brunick, RDH, MS Boise State University
University of South Dakota Boise, Idaho
Vermillion, South Dakota
W. Gail Barnes, RDH, PhD
Geraldine Hernandez, RDH Massachusetts College of Pharmacy
Miami Dade College and Health Sciences
Miami, Florida Boston, Massachusetts

Sandra Horne, RDH, MHSA Chris French Beatty, RDH, PhD

University of Mississippi Medical Center Texas Woman’s University
Jackson, Mississippi Denton, Texas

Jacquelyn W. Johnson, RDH, MS Donna J. Stach, RDH, MEd

Tarrant County College—Northeast University of Colorado
Hurst, Texas Denver, Colorado

Bernice A. Mills, RDH, MS Barbara Paige, RDH, EdD

University of New England Cabrillo College
Portland, Maine Aptos, California

Nichole Oocumma, RDH, MA, CHES Angelina E. Riccelli, RDH, MS

Stark State College University of Pittsburgh
North Canton, Ohio Pittsburgh, Pennsylvania

Carolyn Ray, RDH, MEd

Texas Woman’s University
Denton, Texas
 CHAPTER 1

Introduction to
Moral Philosophy
and Moral Reasoning

OBJECTIVES
After reading the material in this chapter, you will be able to
■ Define the term ethics.

■ Define the terms deontology (deontological approach) and teleology (teleological approach).

■ Distinguish between the ethical theory of utilitarianism and Kant’s ethical theory.

■ Compare rule utilitarianism with act utilitarianism.

■ Contrast a right with a duty and a right with a privilege.

■ Discuss the role of social justice in determining ethical behavior.

KEY TERMS
Act utilitarian Ethics Rights
Consequentialist theory Normative ethics Rule utilitarian
Deontology Prima facie Teleology
Duty Privilege Virtue ethics

INTRODUCTION
Throughout our personal and professional lives, we make judgments and behave according to
moral principles. These actions may be perceived as right or wrong based on their consequences,
an individual’s duties, and virtues or character traits. These perceptions have a profound effect on
our view, as health care providers and as ordinary citizens, of access to health care and other
social justice issues. This chapter serves as a knowledge foundation for decision making and
actions in dental hygiene practice.

1
2 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning

Case Study
After a conversation with your supervising employer dentist about universal health care, you
tell her that covering every individual should be the aim. She argues against this proposition
because this kind of health care coverage will lower the incomes of dentists and the entire
office staff working with them.
As you read this chapter, consider the following: Which ethical theory has guided you
position?

ETHICAL THEORIES: DUTIES AND CONSEQUENCES

In health care and elsewhere, ethical behavior is the result of perceiving an action as either right
or wrong. This perception is based on norms, duties, consequences, and character traits.

Ethics
The discipline of ethics consists of thoughts and ideas about morality. Ethics (or moral thinking)
is concerned with studying human behavior, particularly toward other human beings, and the
principles that can regulate it. Most ethical thinkers are philosophers, and philosophy differs
from social sciences in its tendency to suggest or recommend standards, or norms, of behavior.
For example, a sociologist may study the phenomenon of aggression, focusing on the causes of
aggression and how some members of society become aggressive under certain circumstances.
Similarly, a psychologist may explain why some people fail to develop normal empathic atti-
tudes to others and become indifferent and insensitive to human suffering. A philosopher, on the
other hand, would deal with aggression and insensitivity to suffering as violations of several
moral values and would propose arguments to support the importance of peaceful and mutually
respectful attitudes to human life and to other people.

Normative Ethics
The difference is that science, whether social or physical, is mainly descriptive, while moral
philosophy is mainly normative. Science analyzes phenomena in depth and explains them. It
may also predict future events on the basis of present observations. Ethical philosophy goes
beyond studying phenomena at a descriptive level and proceeds to recommend desirable atti-
tudes. Because desirable attitudes are commonly called norms, ethical thinking that purports to
guide human behavior is called normative ethics.
Traditionally, the ethical studies that explore the nature of moral judgments and the struc-
ture of moral concepts are called metaethics. Metaethical studies investigate, for example, the
meaning or the significance of what is right or wrong (good or evil) and whether moral judg-
ments are objective or subjective (Honderich, 1995, p. 555). Normative ethics is the branch of
metaethics that is concerned with moral recommendations about which acts are right and which
are wrong. The study of normative ethics that is relevant to health care ethics can be divided into
two major groups of theories: deontology and teleology. Virtue ethics is also an important nor-
mative position and will be discussed later in another section of this chapter.

DEONTOLOGY The first normative ethical theory is deontology. Advocates of deontological

ethics emphasize duties. For them, performing moral duties is not a matter of deliberation or
 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning 3

negotiation. A duty is an obligation, an act that has to be done or ought to be done regardless of
its consequences. In that way, deontological ethics shares with religions the concept of absolute
obligation. A deontologist, for example, would expect people to tell the truth no matter what hap-
pens as a result. This is similar to the attitude of a religious person who never lies because lying
is against the Ten Commandments. Ethical duties are derived from ethical principles and con-
cepts. Some of these duties (e.g., truthfulness) are adopted by health care professions and stated
in codes of professional ethics. Other duties (e.g., respect for private property) are incorporated
into the legal system, while others (e.g., respect for personal privacy and helping the poor or eld-
erly) are incorporated into social traditions and customs (Weinstein, 1993, p. 84). Purtilo (1999)
defines three basic duties: absolute, prima facie, and conditional (p. 60). An absolute duty is
binding under all circumstances. For example, the duty not to kill an innocent person is absolute
because we know of no situation in which such killing would be permissible. It is important to
notice here (or in that respect) that having to defend oneself against a non-innocent aggressor,
which may result in killing in self-defense, is not a violation of deontology.
Prima facie duties differ in that they are determined by the present situation. The term
prima facie means “at first glance,” and a prima facie duty is a duty that is made obvious by the
circumstances surrounding it. In dentistry, a scenario to illustrate this is treating the patient who
is in pain before treating the patient who has come for a routine scheduled appointment. Treating
the patient in pain seems to be the right decision even though it may upset the scheduled patient
because of unexpected waiting.
A conditional duty is a commitment that comes into being after certain conditions are met.
For instance, our society has a duty to support unemployed persons only after they try to learn
new skills that may enable them to find jobs, or after it becomes obvious that they have no chance
to find employment. Similarly, we have a duty to support medical research only after ensuring
that it is well designed, feasible, and concerned with major health problems rather than with aca-
demic curiosities. Duties are further discussed in this chapter and in Chapter 2.

TELEOLOGY Thus far, we have discussed the deontological group of theories. Let us examine
the second group of normative theories, which is called teleological theories. The term teleology
is derived from the Greek word for “end,” or “goal.” A teleologist will consider the consequences
of telling the truth versus the consequences of lying and may find that lying is morally justified
in a specific circumstance. This position, which is also called consequentialism, is based on the
notion that what matters for morality is the result, or consequence, of an action. Telling a “little
white lie” that will do more good than telling the truth counts, for teleologists, as a good action.
For example, a teleologist would say that lying to a known killer about the hiding place of his
potential victim is morally good. So the difference between deontologists and teleologists is that
the former are concerned with the principle behind an action, while the latter are concerned with
the results of an action.

ETHICAL THEORIES: A SURVEY OF MORAL THEORIES

In this section, three ethical theories will be discussed: utilitarianism, Kantian ethics, and virtue
ethics. These theories provide a background or rationale for making moral judgments.

Utilitarianism
UTILITY AND CONSEQUENCES The first utilitarians were the British philosophers Jeremy
Bentham and John Stuart Mill, who lived in the nineteenth century. They argued that the aim of
4 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning

morality is attaining the greatest amount of utility for human beings and identified utility (or use-
fulness) with happiness. Their theory, which became popular during much of the twentieth cen-
tury in Britain and North America, is a consequentialist theory. Consequentialist (teleological)
theories are based on the results of actions rather than on the nature of actions. For instance, if
telling a lie can lead to saving an innocent life in a particular situation, it is morally good to tell a
lie in that situation. That is, an action is morally right if it leads to desirable results and is wrong
if it leads to undesirable results. Utilitarianism defines the “good consequence,” or “desirable
result,” as the maximal happiness in the world (i.e., happiness for most people). According to
utilitarianism, suffering is the ultimate evil and happiness the ultimate good, and the role of
morality is to guide us to eliminate suffering and maximize happiness.

HAPPINESS Utilitarianism does not recommend that every person pursue only what promotes
his or her happiness. Instead, it recommends that all persons act in a way that leads to the least
misery and the most happiness (including personal happiness) in the world. The utility principle
recommends that we seek the “general” or “total” happiness in society rather than our own per-
sonal happiness. However, utilitarians do not ask us to ignore our own happiness but rather to view
it as a part of total happiness. In that respect, utilitarianism adopts the principle of beneficence,
which is discussed in Chapter 2. The beneficence principle requires one to do what is good for
others without expecting a reward for doing so. Box 1-1 gives an example of utilitarianism.

BOX 1-1
Example

To understand utilitarianism, consider this example. A healthy man knows that his neighbor’s daugh-
ter needs a kidney transplant to survive after a disease has destroyed both her kidneys. He volunteers
to have his tissues tested for compatibility with the girl’s tissues, and the result turns out to be posi-
tive. If he donates his kidney to save the girl’s life, he exposes himself to a major surgical operation.
He also knows that if he lives with only one kidney, there is a small chance of having a disease in that
kidney in the future that may be severe enough to kill him. Donating his kidney would cost him at
least some peace of mind. Should he accept this price (i.e., some anxiety about future health) and
give the girl one of his kidneys? Utilitarians would encourage him to do so as long as he is unlikely to
be significantly harmed. By saving her life, he makes her and her family and friends happy. He also
makes people who advocate benevolent actions happy by giving a good example of benevolent
behavior that may inspire others. The outcome of his action, then, would be more happiness in the
world, and this agrees with the utility principle.
But utilitarians would not encourage a person who is likely to be harmed by a surgical opera-
tion to donate his kidney. As soon as the girl and her family realize that the benevolent man has
exposed himself to a great danger, they would feel sorry rather than happy and thankful. At the same
time, the man’s own family and friends would be unhappy if he is harmed. In the end, his action
would not add to the total happiness in the world and is therefore unethical on utilitarian grounds.
So utilitarianism does not expect from any individual sacrifices that would not maximize happiness
and minimize suffering for the greatest number of people.
 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning 5

When utilitarians discuss happiness, they do not mean any form of happiness. Happiness can
be shallow, short lasting, significant, long lasting, hedonic (in the form of pleasurable feeling), or
intellectual (e.g., enjoying an artwork). Short-term happiness is not the aim of utilitarianism. No
utilitarian, for example, would encourage a student fond of sports to abandon school to satisfy the
passion for sports or an art lover with limited resources to spend most of her income collecting
paintings. It is also important to recognize that utilitarianism does not construe happiness merely as
pleasure. Satisfaction in general, whether it derives from meeting one’s basic needs, reading inter-
esting novels, or helping the poor, would count as happiness for utilitarians. Another important
point is that utilitarians regard reducing suffering (or decreasing unhappiness) equivalent to
increasing happiness in the world. A dental hygienist who donates time to a public aid clinic think-
ing that the consequences will bring happiness to others is guided by the utility principle. If the den-
tal hygienist who donates time to the public aid clinic instead of working for a salary is not able to
provide for his or her children, then he or she is not following the utilitarian principle.

CATEGORIES OF UTILITARIANISM There are two versions of utilitarianism: act utilitarianism

and rule utilitarianism.
• An act utilitarian is concerned with individual acts. This person would assert that acting
in a certain way (e.g., keeping promises) promotes general happiness, and for that reason,
it is a good action.
• A rule utilitarian, on the other hand, is concerned more with the rule from which an
action is derived. He or she would assert that the goodness of an action depends on whether
it is justified by a rule that, if followed, can maximize happiness in the world.
There seems to be no substantial difference between the two positions. However, in some
situations, rule utilitarianism can avoid problems that act utilitarianism cannot. As dental hygien-
ists, we know that polishing teeth can damage tooth structure (Wilkins, 2009). Many patients feel
that they have not received complete treatment unless the teeth are polished even though they are
told about the disadvantages of polishing (patient may not have stains, polishing is contraindi-
cated, no therapeutic reason). In order to provide happiness to the patient, the dental hygienist
gives the illusion of polishing by sweeping the rubber cup over the surfaces of the teeth with
minimal or no pressure. The patient feels the act of polishing and tastes the polishing agent.
It is difficult to describe a deceptive act as morally good, yet a rule utilitarian would not
agree that the dental hygienist’s action was good because adopting the rule that deceiving people
in order to please them would not maximize happiness. Rational people would feel unhappy and
even angry if they knew that they were deceived in order to be pleased. It would be wrong to sug-
gest to a patient that a procedure was done when in fact it was not.

RELEVANCY OF UTILITARIANISM Is utilitarianism relevant to health care ethics? Yes, because

this theory is concerned with reducing suffering, which is one of the main duties of health care
providers. Moreover, utilitarianism contributes significantly to the discussion of the problem of
fair distribution of health care resources.

Case Study Follow-up #1

In the chapter’s case study, the dental hygienist is taking the position of a utilitarian or
using the utilitarianism ethical theory to defend universal health care. The dental hygienist
perceives that universal health care will bring happiness to most people.
6 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning

Kantian Ethics
MORALLY RIGHT ACT OR A DUTY According to Immanuel Kant, the eighteenth-century
German philosopher, certain acts are morally right because they are intrinsically right regardless
of their consequences or results. Consequences, he asserts, should not matter when the moral
value of an action is assessed. Kant even argues that consequences are relevant to practical mat-
ters, not to ethics. In the practical realm, one has to ask will this action can lead to good results and
act accordingly. For example, a student may decide to study engineering because engineers have
good careers. Such a decision is based on consequential (teleological) considerations: studying
engineering qualifies one to enter a stable and rewarding career. When that student decided to be
an engineer to enjoy the benefits that result from this decision, he or she was making a consequen-
tialist but purely practical decision. But the situation is different in the moral realm.
In the moral field, there are acts that must be done whether or not they lead to desirable or
undesirable results. Therefore, these acts are moral duties, Kant asserts. These acts lose moral
worth when they are done to attain an aim. For example, if you do not tell lies because you want
to impress people and get their support or votes, you are either acting practically (from practical
motives) or immorally (by trying to exploit ethical principles for material gain). However, if you
do not tell lies because you believe that lying is morally wrong, you are acting morally. In other
words, you are performing a moral duty. Because Kant’s ethics is concerned with duties and
reduces moral principles to duties, it was called deontological (from the Greek deon, meaning
“obligation”).

MORAL PRINCIPLES Kant opposed deriving moral principles from accidental events and con-
tingencies because that could lead to formulating contradictory principles. Suppose that a free-
dom fighter in Poland during World War II gave the Nazi officers who were interrogating him
false information about the identities of his partners. By doing that, he saved their lives and
served a good cause. But can we derive from that circumstance a principle that justifies telling
lies when it is convenient to do so? Kant’s answer is an unequivocal no. For him, ethical princi-
ples cannot be subjected to negotiation, nor should they be modified to adapt to new situations
when it appears useful to modify them. It is wrong, he believes, to modify one’s commitment to
truth telling in light of the present circumstances. Moral principles, Kant insists, should be based
on solid foundations then followed with total disregard for the context. If we believe that truth
telling is good, we must always tell the truth even if that leads to great harm in a particular con-
text. Thus, the Polish freedom fighter did not act according to sound moral principles when he
lied to the Nazis, in Kant’s opinion.
Kant acknowledged that it is sometimes harmful to follow moral principles faithfully. He
knew very well that, at least in exceptional cases, we might do better by violating moral princi-
ples. But he argued that repeated violations could send a harmful message to people. Violations
(or variations) may suggest that one is encouraged to violate moral principles when it seems use-
ful to do so. Kant believed interpreting moral principles in a relative way permits us to lie today
and then tell the truth tomorrow and opens the door for moral confusion and chaos.
Consequently, moral principles should be absolute (unmodifiable). So the main issue in Kantian
ethics is that there are categorical (absolute) imperatives (duties) that are inescapable. They can
be inferred by reason and should be generalized.

MORAL DUTY Kant’s contention that duties are categorical is disputable. However, his view
that we must treat all people as ends in themselves, not as means, is widely respected. How does
 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning 7

he argue for that principle? According to Kant, every human being is a rational person. And
rational persons appreciate and value their rationality. As a result, they would not accept being
used or treated as means. Their self-respect and respect for the value of rationality would not
allow that. It follows that no person should accept being treated as a means to other ends and that
every person ought to be treated as an end in himself or herself. This principle is highly esteemed
in ethics and in health care ethics in particular. As will be seen later, it follows from this princi-
ple that people should not be treated as objects, and as a result, their well-being (and health)
should not be treated as a commodity. Using the previous example, the dental hygienist who
donates time to a public aid clinic because it is a moral duty—even if this means losing salary,
sacrificing leisure time, or denying his or her children small pleasures—to help the disadvan-
taged is guided by deontological or Kantian principle.

Case Study Follow-up #2

In the chapter’s case study, what is the moral duty of the dentist?

Virtue Ethics
CHARACTER TRAITS Virtue ethics places emphasis on character traits of individuals and was
advocated by the early philosophers such as Socrates, Plato, and Aristotle. According to them,
virtue is the basis of morality. They regarded persons of excellent character as moral persons.
That is, a virtuous person is essentially a person who acts morally. The virtue approach to ethics
demands that every person think and act in the best way possible for a given situation (Ozar &
Sokol, 1994, p. 4). For example, a virtuous person would advocate fairness and equal respect for
people’s interests when a conflict between individuals arises and requires mediation or arbitra-
tion. He or she would also recommend kindness to animals, honesty in financial dealings, and
truth telling. In other words, virtuous people are disposed to think and act morally. This disposi-
tion (or readiness to act in a certain way) is taken by the proponents of virtue ethics as the guide
to moral judgments.
Advocates of virtue ethics expect and require every person to act like a virtuous person.
By doing so, they act in a morally good way. This shows that virtue ethics relies on the moral
inclination of people with excellent personal qualities to identify the morally right and wrong.
Obviously, this approach differs from other systems or theories of metaethics (e.g., deontology
and teleology) that rely on rules, principles, consequences, or goals. That is, virtue ethics tells
us to act the way a virtuous person would act in a similar situation, while other theories tell us
to act according to the principle or rule that suits the situation. Such a principle or rule may
derive from Kantian or utilitarian theories, for example. Box 1-2 reviews the types of norma-
tive ethics.
Historically, the ancient virtue ethics emphasized the cardinal virtues of temperance, jus-
tice, courage, and wisdom. In the Middle Ages, Christianity added the theological virtues of
faith, hope, and charity. Many feel that a person cannot possess one virtue without the other and
that all virtues are interrelated or interdependent. In other words, a person who is courageous and
truthful would also be fair and benevolent. But virtue ethics, which was ignored in modern times,
is no longer dead. There are contemporary philosophers who think that a focus on virtue, not on
abstract principles, can form the basis for morality (Honderich, 1995, p. 901).
8 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning

BOX 1-2
Types of Normative Ethics

Teleology: type of ethics that emphasizes consequences

Deontology: type of ethics that emphasizes duties
Virtue ethics: type of ethics that emphasizes character traits

SOCIAL PHILOSOPHY
Social philosophy deals with issues like justice, rights, and equality. Problems in medical ethics
that belong to the area of social philosophy include, among other things, equal access to health
care resources and patients’ rights.

Utilitarianism and Justice

SOCIAL JUSTICE Utilitarianism is meant to be a social philosophy as well as a general theory
of normative ethics. The utilitarian view of justice is considered the most important compo-
nent in the social aspect of utilitarianism. Utilitarians understand social justice as a means to
happiness. They argue that satisfying basic needs leads to more happiness than does enjoying
luxuries. A nice weekend in Hawaii would make any person feel happy. But there are degrees
of happiness. Compare the happiness that a vacationing person in Hawaii would experience with
the happiness that a starving, chilled person would experience when fed and warmed. The
utilitarians are warranted in asserting that satisfying essential needs creates greater pleasure
than satisfying less basic needs. Moreover, lacking basic needs, such as adequate food and
shelter, is apt to create suffering, while giving up some luxuries is unlikely to produce signifi-
cant discomfort.
Consequently, taking some resources from people who have already satisfied all their basic
needs and giving them to those whose basic needs are not satisfied would increase the amount of
total happiness in the world. And this is the declared aim of utilitarianism. So justice, as con-
ceived by utilitarians, is a process that is meant to maximize happiness and reduce suffering. It is
not an end in itself, though.

HEALTH CARE IMPLICATIONS The implications of social justice for health care ethics are
great. A society in which the majority of people are unable to obtain health care cannot be called
a happy society. Sickness produces suffering and undermines happiness; and whenever the num-
ber of sick or improperly treated people in a society is large, happiness in this society is limited.
It follows that making health care resources available for all or most members of society is essen-
tial for keeping the level of happiness in that society sufficiently high. This is how utilitarians
justify the necessity of distributing health care resources (or goods) fairly among all people. It is
important to notice that utilitariansim calls not for complete equality but rather for the extent of
equality that keeps most people healthy and free of suffering.
 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning 9

Liberalism and Rights

RIGHTS Social philosophy talked about duties but not rights until John Locke, the 18th-century
British philosopher, emphasized the concept of natural rights. Locke’s aim was to fight the
tyranny of European governments and the vulnerability of the ordinary citizen to the unrestricted
power of governments. He argued that human beings are born with rights attached to them by
nature, including the right to freedom (autonomy), life, property ownership, and free expression.
The elite were the only people granted these rights at that time. Even the elite, other than the
monarchs, were not allowed free expression in most circumstances. Citizens in Locke’s time
were granted limited rights through government decrees and statutes. These did not include the
right to free speech or the pursuit of personal happiness.
In the Constitution of the United States, Americans were granted the right to life, liberty,
and the pursuit of happiness. Additional rights, such as freedom of speech and bearing arms,
were given later in the U.S. Bill of Rights. The notion of rights has advanced social and political
philosophies to a large extent. In fact, the notions of human rights, equal civil rights, and freedom
from oppression that dominated the twentieth century’s movements of social and political reform
were inspired by liberalism. Furthermore, the political aspect of liberalism is behind most of the
principles of international law.

DUTY A right is defined as a valid claim. If a person is entitled to voting privileges and there
are no sound legal reasons for denying this entitlement, he or she has a right (valid claim) to vote.
This right allows him or her to expect other members of society not to interfere with his or her
going to the polls and casting a vote. Rights, then, protect one’s interests by imposing correspon-
ding duties on other people to respect the interests of a right holder. In other words, every right
has a corresponding duty on the part of other society members. Without such duty, exercising a
right would be difficult. For example, your right to privacy cannot be exercised if your society
does not consider it a duty to protect you from intruders. This is why no citizen in the former
Soviet Union had a right to free speech: Citizens had no duty to help any person to express his or
her opinions.

Three Facts about Rights

There are three important points about rights.

RIGHTS ARE NOT PRIVILEGES There are three important points about rights. First, rights dif-
fer from ordinary freedoms (privileges). For example, every person is entitled to play chess or to
go to music concerts. But no person should expect others to help him or her play chess or go to
concerts because our society does not impose on us a duty to help other people enjoy freedoms.
Yet every person expects others to help protect his or her property or privacy (either directly or
by supporting the institutions that enforce law and order in society).

MORAL AND LEGAL RIGHTS Second, there are moral rights and legal rights. Moral rights
include the right to life, autonomy, and equality before the law. A moral right is a valid claim that
is based on moral (ethical) reasons. For example, the right to life is based on the ethical principle
that killing is wrong, and the right to autonomy is based on the principle that it is morally wrong
to control other individuals. Although many moral rights are protected by law in most societies,
some are not, so not every moral right is a legal right. Until the nineteenth century, for instance,
slavery was legal in the United States. The moral right to autonomy was not considered a legal
right at that time.
10 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning

Some legal rights may not be moral rights. For example, firing workers without significant
compensation and when there is no economic need for reducing the workforce is a legal right for
employers in the United States but not in Germany or Sweden. Germans and Swedes, among
others, think that this right is based on an unfair principle that ignores the well-being of workers.
For an ethicist, the right of an employer to dismiss workers arbitrarily may seem difficult to
accept on moral grounds although it is allowed by law.

RIGHTS ARE NOT ABSOLUTE They can be revoked or suspended. For example, a criminal is
deprived of his right to autonomy when he is kept in jail. Similarly, the right to free speech is
restricted by the rights of other people not to be defamed or slandered. It is true that people have
the right to express their opinions, but it is also true that they should not misuse their rights and
insult or humiliate others in the process.
Is liberalism relevant to health care ethics? It enables medical ethics to utilize the concept
of patients’ rights and providers’ corresponding duties to such rights. Without the concept of
moral rights, which Locke called natural rights, it would be difficult to explore areas like pri-
vacy, confidentiality, informed consent, and paternalism. That will be seen more clearly in fol-
lowing chapters.
A right must not be confused with a privilege. As stated previously, a right is guaranteed
for all persons. But privileges are not guaranteed (though not denied) for any person. No individ-
ual is entitled to claim the privilege of owning an expensive car or obtaining a license to practice
dental hygiene. These privileges must be earned by effort and hard work. They are not guaran-
teed to whoever wants them. If a person wants to practice dental hygiene, he or she has to meet
certain conditions required for licensure. Compare that with the right to life, for example. The
right to life cannot be withheld, is not earned, and is guaranteed for all. Box 1-3 names three
characteristics of rights.

CONTROVERSIES IN THE UNITED STATES Controversies have arisen in the United States as to
whether health care (including dental hygiene care) is a right for all residents or a privilege for
those who can afford it through personal wealth or the ability to pay for insurance. And, if health
care is ever guaranteed for all citizens, which benefits and procedures would be granted to every
person who needs them? Would every treatment modality, regardless of its cost, be made avail-
able to all citizens who would benefit from them? Another controversy is education. Should post-
secondary education be a privilege only for those who can afford the tuition? These are just a few
examples that help distinguish privilege from right.

BOX 1-3
Characteristics of Rights

• For every right there is a corresponding duty.

• A right is guaranteed while a privilege is earned.
• A right can be taken away.
 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning 11

Rawls’s Theory of Justice

John Rawls is a contemporary American philosopher whose main concern has been social jus-
tice. He proposed a theory in the early 1970s that characterizes social justice as a fair deal that
members of society negotiate and abide by (Rawls, 1971).

JUSTICE AS AN END IN ITSELF Contrary to the utilitarian view of justice as a means for happi-
ness, Rawls asserts that justice is an end in itself. It is a situation that rational members of soci-
ety desire and aspire to attain. Therefore, its principles cannot be arbitrary. These principles
should be carefully sought and formulated. Meanwhile, the principles of justice cannot be
reached by speculation that fails to consider the real wants and needs of people in society. If
philosophers introduce principles of justice that are theoretically elegant and admirable but prac-
tically unrealizable or unacceptable to the average person, these principles will never work.

AGREEING ON WHAT IS JUST Rawls’s idea is that people do not need a profound thinker to
advise them about justice. Rather, they need to reach an agreement among themselves, based on
rational debate, that they accept and enact. People need to think impartially to reach a lasting
agreement. Our experience with modern science tells us that scientists agree easily on the same
conclusions and interpretations of data because they think impartially. Practitioners of science,
when they strictly follow the scientific method, can be impartial. But impartiality is more diffi-
cult to achieve in daily life, where various kinds of biased attitudes influence people.
Yet Rawls finds a way out. He believes that people will be impartial if they are ignorant
about their personal status, economic situation, and social standing. The reason is that people
will not be biased to a group, profession, or class if they have no idea about where they stand.
Imagine that you do not know whether you will be a professional, a merchant, a skilled laborer,
or a manual worker. Would you take sides with those who demand equal tax cuts for every citi-
zen so that the rich do not pay more than the poor? Or with those who advocate raising the min-
imum wage? Perhaps you would be rather neutral on both issues. But a low-income worker
would typically side with the latter issue, while an owner of a corporation would side with the
former. This seems natural because people tend to favor the proposals and plans that serve their
own interests. This assumption that people act from self-interest underlies Rawls’s theory.

VEIL OF IGNORANCE Rawls calls the situation in which people can be impartial the original
position. In this imaginary situation, people would discuss justice with (to speak metaphori-
cally) a veil of ignorance in front of their eyes. Only in this situation, Rawls believes, could
people think without preconceived biases and therefore reach reasonable agreements. His line
of reasoning is that people think, argue, and act from self-interest. If someone knew that he or
she would be a nuclear physicist, that person would believe that it is just to reward people with
intellectual abilities. If the same person knew that he or she would be a factory worker, he or
she would think that people should be rewarded according to the physical effort they expend to
produce goods. However, if people were in the original position, they would agree on a system
of principles that causes the least harm to any of them if they turn out to be in the least privi-
leged class or group.
Rawls supposes (with good reasons) that in the original position, people would agree on
principles that promote mutual self-interest and that they would not agree except on principles
that further the interests of them all. Thus, self-interest in combination with rational thinking
would impose a cautious attitude. Rational, self-interested people would not take risks; they
would be careful. They would not assume that they might eventually be in the elite class, so in
12 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning

order to avoid harming themselves if they happen to be in a lower position, they would not
choose principles that favor the top class. Rawls assumes that ignorance about one’s future posi-
tion would suppress the gambling, irrational attitude in people and would motivate them to think
cautiously. In other words, they would be guided primarily by risk aversion.

BASIC LIBERTIES Self-interest, moreover, would guide people to insist on equal basic liberties
for all. Such liberties include free speech, autonomy, equal opportunities, and similar essential
freedoms. Not many people, in Rawls’s opinion, would be willing to sacrifice these badly needed
liberties. Self-interest would also direct them to prefer abundance with some degree of inequal-
ity to equality with scarcity because satisfying basic needs comes before the need for fairness, at
least for most people. As Rawls sees it, any person would prefer to have a big piece of a large pie
that is cut into unequal but sizable pieces rather than a tiny piece of a smaller pie that is cut into
exactly equal pieces (so that every person gets an equal share). That is, Rawls thinks that every
reasonable person would say, “I want to eat enough, no matter how much the other guy is eating.”
What Rawls wants to conclude here is that justice cannot be absolute and that the demand for
justice is restricted by other factors, particularly by the need for abundance.
It follows that if the motivation to work productively (which is essential for affluence)
requires inequality (which will result from rewarding productive more than nonproductive peo-
ple), it would be reasonable to allow the least possible degree of inequality required for increas-
ing productivity. Based on this situation, people will conclude that justice can be established on
two basic principles, commonly called Rawls’s two principles of justice.

RAWLS’S TWO PRINCIPLES OF JUSTICE The first principle says that each person has an equal
right to the most extensive scheme of equal basic liberties that a society can afford. These liber-
ties should be guaranteed for each person to the extent that they do not undermine the liberties of
others. That is, no person can have a degree of liberty that, for being too much, decreases the
amounts of liberties available to others (and consequently leads to inequality).
The second principle says that social and economic goods may be distributed unequally
under two conditions. First, these inequalities should work for the benefit of the least advan-
taged. Second, they should be made open to fair competition in which all members of society
can participate. All precautions must be taken to ensure that any person can fairly compete
for advantaged positions. That is, these privileged positions must be given only to those who
deserve them, not to members of an elite or favored class. Box 1-4 summarizes the two prin-
ciples of justice.

BOX 1-4
Two Principles of Justice

• Each person has equal right to liberties as long as it does not mean that others have lesser
unequal liberties.
• Social and economic goods may be unequal if (a) the inequalities work for the benefit of the
least advantaged, and (b) there is open and fair competition for all to participate.
 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning 13

Why should the least advantaged be favored? This is an important question that poses itself
at this point. Rawls’s answer is that inequality is not a prize given to the gifted to express our
admiration. It is a “carrot” to tempt the gifted to do their best for others. This is not an exploita-
tion of the gifted, though. A gifted person may argue that hard work, not merely talent, earned
him or her success. However, the motivation to work hard is determined by a personal quality
that is derived from genes. What comes from nature is a resource, like water and minerals, and
resources are liable to fair distribution. Unequal income, then, is not naturally deserved by the
gifted but was granted them in a deal that was negotiated in the original, hypothetical position.
Less gifted people chose to allow for such a privilege (which they could have chosen not to grant
to the gifted) in return for a commitment by the gifted to pay back.
Rawls would, for example, say, “If you are an excellent entrepreneur while I am an ordinary
person, I still have some right to your achievements because your intelligence is an asset like other
natural resources. If your talent does not work for my advantage, you have done injustice to me
because your talent (or resources like oil wells or rivers) should be used for everyone’s benefit.”
So, according to Rawls’s theory, the talented should realize that they have already entered an
agreement in the original position to work first for the least advantaged. If they change their minds
after becoming privileged, they should be reminded of their initial judgment and agreement,
which was made when impartiality was possible (i.e., under the veil of ignorance).

Applying Rawls’s Theory to Health Care Problems

How does this theory fit into the problems addressed by health care ethics? Remember that
health care goods are limited, while the needs for them are immense. That is, there is a relative
but significant scarcity of health care resources. These resources need to be distributed carefully.
Should we allow the rich to have the best resources for themselves because they can afford to pay
for them? Utilitarians disagree because favoring the rich or any particular section of society lim-
its the general happiness to this section alone and lets the suffering of other sections grow. The
ultimate result is a reduction in the total happiness in society, which is morally undesirable.
However, Rawls rejects tying justice to happiness. Yet he reaches the same utilitarian con-
clusion: Health care resources should be distributed fairly among all members of society. How
does he justify this answer? Recall the original position. If people are in that position, which is
conducive to impartiality, they will choose the arrangement that exposes them to the least risk.
Since none of them knows whether he will be healthy or ill or able to pay medical bills or even
buy necessary medications, he will choose a system that makes the most privileged responsible
to work for improving the situation of the least advantaged.

EQUAL ACCESS TO BASIC HEALTH CARE Reflect on the conclusions of utilitarianism and
Rawls’s theory. Both favor an arrangement that ensures that all—or at least most people—get
equal access to basic health care services (e.g., emergency care and immunizations) and almost
equal access to every other form of essential health care service. Utilitarians want that arrange-
ment to increase the happiness in the world, and Rawls wants it because it agrees with people’s
attitudes and inclinations, at least when they think impartially. A system of national health insur-
ance would be ideal for both philosophies, although any system that guarantees affordable care
for every member of society would be acceptable to them.
Health care can be viewed as an economic good. Concerns regarding the equitable access
to health care or health services are addressed with two theories: market justice and social jus-
tice. Shi and Singh (2004) provide the following comparison: Market justice views health care as
14 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning

an economic good, based on demand and one’s ability to pay and as an economic reward. Thus,
each individual is responsible for his or her own health. In addition, in market justice, benefits
are based on the purchasing power of every individual. Social justice, on the other hand, views
health as a social resource and a basic right. According to social justice, one’s ability to pay is not
a condition for receiving medical care, and the government is involved in health service delivery.
So this view considers health care a collective (public) good (p. 59).

PRACTICAL RESTRICTIONS Ideally, every person should have access to any form of health care
that he or she needs. But the scarcity of resources imposes practical restrictions on distributing
health care services and necessitates drawing a distinction, however arbitrary, between “badly
needed” and “less urgently needed” services. Unfortunately, not all dental care or preventive
dental hygiene care is considered “needed” health care in terms of insurance or government
assistance programs (see Chapter 6). Let us hope that future advances in technology succeed in
reducing the cost of health care.

Case Study Follow-up #3

Do you think health care is a right or a privilege? If a right, what is your duty?

Summary
The discipline of ethics consists of thoughts and not guaranteed and must be attained by personal
ideas about morality. The study of normative ethics effort or optional help from people who want to
can be divided into two major groups of theories: provide such help. Although no person is obli-
deontology and teleology (consequentialism). gated to help others attain a privilege, there is no
Deontological theories (Kant’s ethics) emphasize moral rule that forbids volunteering to help some-
duties, while teleological theories emphasize con- one to gain a privilege in a way that does not harm
sequences of actions. Utilitarianism is a teleologi- others. Utilitarians view social justice as a means
cal theory concerned with attaining the greatest to happiness, and for this reason, they pursue jus-
amount of utility, usefulness, or happiness. Social tice. Because utilitarianism considers justice a
philosophy is concerned mainly with rights of peo- moral goal, it recommends that society allocate
ple and social justice. A right is a valid claim and is goods and services, such as health care resources,
ensured for all people. A privilege, by contrast, is in a fair way.

Critical Thinking
1. How is the study of ethics different from other dis- 4. According to utilitarians, what is the role of the
ciplines (or courses) you have previously studied? utility or the consequences of an action?
2. Compare the term deontology with the term teleo- 5. Give an example of (a) a right, (b) a duty, and (c) a
logy. privilege.
3. What is the major difference between a rule utili- 6. Explain how John Rawls’s theory of justice is a
tarian and an act utilitarian? theory of social justice.
 Chapter 1 • Introduction to Moral Philosophy and Moral Reasoning 15

7. Divide into groups. Relate to one another situations regarding patient care or a public health need.
in which decisions had to be made. Classify the Select an ethical theory. Defend the decision using
decisions based on the basis of the ethical theories the selected ethical theory.
or approaches. Present these findings to the class. 9. In pairs, role-play the dentist and the dental
Does the class agree with your classifications? hygienist as described in this chapter’s case study.
8. Design a case study or scenario that would involve 10. Hold a debate in class: Is health care a right or a
a decision that a dental hygienist may have to make privilege?
 CHAPTER 2

Core Values
and Additional
Ethical Principles

OBJECTIVES
After reading the material in this chapter, you will be able to
■ Identify the core values found in the Code of Ethics of the American Dental Hygienists’

Association, the five main principles articulated in the Code of Ethics of the Canadian Dental
Hygienists Association, and the two values embedded in the Code of Ethics of the
International Federation of Dental Hygienists.
■ Compare other codes of ethics found in the dental hygiene profession at the local, state,

provincial, and national levels.

■ Define the terms autonomy, confidentiality, societal trust, nonmaleficence, beneficence,

justice, veracity, fidelity, paternalism, and utility.

KEY TERMS
Autonomy HIPAA Paternalism
Beneficence Justice Trust
Confidentiality Nonmaleficence Utility
Fidelity Parentalism Veracity

INTRODUCTION
Decisions and actions of health care providers are guided by ethical principles and core values.
These core values are based on the Hippocratic oath and similar codes. They have evolved
through the years as professions formulate their individual codes of ethics. The importance of a
code of ethics in the practice of dental hygiene is illustrated in the curriculum document
Competencies for Entry into the Profession of Dental Hygiene. The first core competency for all
the roles of the dental hygienist: Apply a professional code of ethics in all endeavors (American
Dental Education Association, 2003; www.adea.org)
16
 Chapter 2 • Core Values and Additional Ethical Principles 17

This chapter will focus on the core values and additional ethical principles found in
professional codes of ethics. Examples of how these principles can determine actions taken are
provided to demonstrate the application of these principles in dental hygiene practice and other
situations. Health information is also protected through legislation such as the Health Insurance
Portability and Accountability Act (HIPAA).

Case Study
During a routine dental hygiene recall appointment for a 15-year-old female patient, you
notice that she has plaque around the mandibular first premolar areas. These two teeth
are rotated and in linguoversion. The patient has spoken to you about her concern about the
unappealing appearance of her “lower” teeth and what can be done to make her smile more
flattering. Additionally, she states that she finds these two areas very difficult to floss and
to brush.
Both you and the dentist recommend to her and to her parents the possibility of
orthodontic treatment for this area. The family has insurance coverage and is faithful about
keeping recall appointments and other treatment needs such as sealants and restorations.
However, the father is reluctant to obtain information regarding an orthodontic referral.
The father protests and refuses to discuss the treatment, citing his spiritual belief that pro-
hibits “changing creation” and “science’s interference with Mother Nature.”
As you read this chapter, consider the following: What ethical principles does the
dental hygienist need to consider when developing a treatment plan for this patient?

CORE VALUES
Core values are selected ethical principles that are considered central to a particular code of
ethics. In the Code of Ethics of the American Dental Hygienists’ Association (ADHA), seven
core values are identified: autonomy, confidentiality, societal trust, nonmaleficence, benefi-
cence, justice, and veracity (www.adha.org). These are listed in Box 2-1. Similarly, the Code of
Ethics of the Canadian Dental Hygienists Association (CDHA) names five main principles:
beneficence, autonomy, privacy and confidentiality, accountability, and professionalism (www.
cdha.ca). Likewise, the Code of Ethics of the International Federation of Dental Hygienists
(IFDH) states two values: integrity and respect which includes honesty, respect for individual
choices, and patient confidentiality (www.ifdh.org). Additionally information can be found at
these websites.
The ADEA Statement on Professionalism in Dental Education, including dental
hygiene education, identifies six values: competency, fairness, integrity, responsibility,
respect, and service-mindedness (ADEA, 2009; www.adea.org). These values were adapted
from Codes of Ethics of the American Dental Association, the American Dental Hygienists’
Association, and the American Student Dental Association. Furthermore, application of this
definition of professionalism is made regarding the behavior of students, faculty, researchers,
and administrators especially as they oversee educational institutions. Thus, ethics and pro-
fessionalism do interact.
18 Chapter 2 • Core Values and Additional Ethical Principles

BOX 2-1
Core Values of the ADHA Code of Ethics

Autonomy To guarantee self-determination of the patient

Confidentiality To hold in confidence or secret information entrusted by the patient
Societal Trust To ensure the trust that patients and society have in dental hygienists
Nonmaleficence To do no harm to the patient
Beneficence To benefit the patient
Justice To be fair to the patient; fairness; treat all patients equally
Veracity To tell the truth; not to lie to the patient

Autonomy
The first core value is autonomy. Autonomy is self-determination. An autonomous person
controls his or her own actions, behavior, and inner life (i.e., plans, goals, convictions, and
beliefs). He or she also decides which values to advocate, which faith to adhere to, and which
lifestyle to adopt.
As seen in Chapter 1, the Kantian principle of respect for persons implies that every indi-
vidual should be valued and appreciated. It follows that the preferences of every person should
be respected by fellow human beings. This is how the Kantian principle substantiates the con-
cept of autonomy. The right to autonomy is among the fundamental rights emphasized by liber-
tarian philosophers and proponents of human rights. Although the right to autonomy began as a
moral right, that is, a right that morality calls for, it soon became an essential component of our
legal rights.
Individuals should be able to decide for themselves what actions they will undertake even if
these seem foolish to others. There are limits to autonomy. People are free to behave as they
choose only as long as they do not harm others. Indeed, harm is the main restriction on autonomy.
Fortunately, we can all be autonomous without harming each other because it is easy for rational
persons to consider the interests of other persons and to act in a way that preserves them.

INFORMED CONSENT What are the implications of autonomy for health care? If competent
adults are granted the right to autonomy, they should be permitted to accept or refuse any actions
that affect their lives. Consequently, competent patients (and guardians or parents of incompetent
patients) should be allowed to accept or refuse treatment. Some patients have limited knowledge
of health-related issues and therefore cannot decide on a proposed treatment unless they are
informed about its effectiveness, cost, likelihood of success, side effects, and so on. As a result,
it is the right of a patient to have adequate information about an action, such as an operation, that
will affect his or her life. With this information, the person can agree to a treatment plan or refuse
it. This is precisely how the notion of informed consent, discussed in the next chapter, is derived
from the right to autonomy.
 Chapter 2 • Core Values and Additional Ethical Principles 19

The ADHA Code of Ethics emphasizes the core value of individual autonomy and the
rights that follow from it: “People have the right to be treated with respect. They have the right to
informed consent prior to treatment, and they have the right to full disclosure of all relevant
information so that they can make informed choices about their care” (American Dental
Hygienists’ Association, 1999, p. 17). Autonomy is also a main principle in the CDHA Code of
Ethics, which highlights the right of patients to make their own choices (Canadian Dental
Hygienists Association, 2002). Also, the IFDH Code of Ethics, outlines respect for persons and
personal dignity, respect for individual choices to accept or decline services, and respect for
human rights, values, customs, and spiritual beliefs (International Federation of Dental
Hygienists, 2003).

Case Study Follow-up #1

In this chapter’s case study, what are the restrictions on autonomy for the 15-year-old patient?

Confidentiality
The core value confidentiality is the avoidance of revealing any personal information about the
patient. Personal information may be sensitive or even embarrassing, and failure to keep it within
proper bounds can harm the patient in various ways. The practice of keeping private information
about patients confidential should extend to all kinds of personal information, not just shameful
or embarrassing information.

PROMISE Confidentiality differs from privacy in that confidentiality involves a promise from a
trusted person. If a person entrusts a friend not to publicize personal information, the friend
implicitly promises to keep the information confidential. Similarly, patients giving their
providers personal information about themselves assume that the providers are implicitly prom-
ising confidentiality (further discussion of confidentiality and privacy is found at www.cdha.
org). Keeping a promise is a moral duty that every ethical theory emphasizes, so it would be
unethical of providers to reveal any personal information relevant to their patients.
Confidentiality is also a legal duty of health care providers and a patient’s right (see Chapter 5).
It is true that patients who voluntarily give personal information to their providers are, in
effect, giving up their right to privacy. The act of sharing information itself implies declining the
right to privacy. But the right to privacy also includes the right to determine what will be shared
with whom. Consequently, individuals declining their right to privacy by sharing personal infor-
mation with providers do not lose their right to determine whether any other individual can have
access to this information. Thus, the provider cannot pass personal information to any party
without permission from the patient.

DISCLOSING INFORMATION Confidentiality may be breached if there is a moral justification

for disclosure or if the patient requests or consents to the disclosure. The Code of Ethics of the
IFDH states: “The dental hygienist holds personal information confidential and uses professional
reasoned judgment in sharing this information (IFDH, 2003; www.idhf.org). For example, one
may disclose confidential information in certain cases to another health care provider if the infor-
mation is relevant to helping the patient. Circumstances that allow for disclosing confidential
information are found in Box 2-2.
20 Chapter 2 • Core Values and Additional Ethical Principles

BOX 2-2
Disclosing Confidential Information

1. In an emergency
2. To protect third parties
3. When required by law (e.g., sexually transmitted disease or child or elderly abuse) or policy of
the practice environment (e.g., quality assurance)
4. When requesting commitment or hospitalization of a mentally ill patient
5. To guardian or substitute decision maker of incompetent patient

(Canadian Dental Hygienists Association, 2002; Gutheil & Appelbaum, 1982, 2000; Purtilo, 1999, p. 154)

A hypothetical example for an emergency in dental hygiene practice would be the follow-
ing. A patient experiences chest pain in the dental chair, and you call for an ambulance. You
remember that the patient told you that he abuses cocaine, and you have documented this in the
medical history. Knowing that cocaine can induce severe, potentially fatal heart disease, you
reveal to the paramedics on their arrival the information about your patient’s substance abuse.
Normally, no information from a patient’s health history can be relayed to another provider with-
out the patient signing a release form.
In this case, however, the information you give the paramedics will help in the diagnosis
and treatment of the present chest pain and potential heart problem. Breach of confidentiality
may occasionally be necessary to protect a third party. For example, a patient has more severe
attrition on his teeth than on his last visit. He states that he grinds his teeth more since his
divorce because he is still angry with his wife. He tells you that he will one day kill his wife for
what she has done to him. Here you have an obligation to protect her by contacting her or the
police because you know that threats made by emotionally upset people can be serious.

PROTECTION OF HEALTH INFORMATION Even as early as 1948, the United Nations in the
Universal Declaration of Human Rights recognized the need for confidentiality in Article 12:
“No one shall be subjected to arbitrary interference with his privacy, family, home or correspon-
dence, nor to attacks upon his honour [honor] and reputation” (http://www.un.org). This right has
developed to include personal data exchange in business, government, and trade. Confidentiality
of medical information goes beyond the patient-provider relationship. In the age of computers
and information technology, confidentiality is harder to maintain. Health care information is
available not only to the health care providers but also to any individual who has access to med-
ical records, such as employees of health insurance companies. Yet a careful provider would not
keep sensitive information on records that can be made available to others.”

Health Insurance Portability and Accountability Act

In an attempt to protect the privacy of health information, the U.S. Congress passed the
Health Insurance Portability and Accountability Act (HIPAA) of 1996 to aid in maintaining
 Chapter 2 • Core Values and Additional Ethical Principles 21

confidentiality of electronic records; however, this act also protects written and oral information.
Canada has also taken steps to protect personal health information by recommending amend-
ments to the Criminal Code of Canada for breaches of privacy (Health Canada, 2002).
Confidentiality is an ethical concern in dental hygiene practice; it is also a legal concern.

PORTABILITY/TITLE I The first part of HIPAA, Title I, guarantees that workers and their fami-
lies are allowed to continue health insurance when they change or lose their jobs. This means that
group health plans could not deny coverage or charge more for it because of past or present poor
health. Also included are limiting the degree that preexisting conditions could be excluded from
coverage, giving the right for small employers and those who lost job-related health benefits to
buy heath insurance, and guaranteeing the renewal of insurance regardless of the health of any-
one included in the policy (Ring, 2003, p. 22).

ACCOUNTABILITY/TITLE II The second part of the act, Title II, became effective on April 14,
2003. In particular, HIPAA protects identifiable health information or protected health informa-
tion, known as PHI, that could identify an individual. That is, PHI is information through which,
if known, the identity of the patient can be recognized. This act outlines the handling of health
information into three major sections: privacy standards, patients’ rights, and administrative
requirements. It should be noted that “if a state has a privacy law that is stronger than HIPAA’s
privacy rule, it will supersede HIPAA” (Ring, 2003, p. 23).

ELECTRONIC TRANSMISSION Privacy standards ensure that the minimal necessary informa-
tion is to be used and disclosed, thereby protecting a patient’s identity and health information.
Anyone or any organization, such as health plans, health care clearinghouses, and health care
providers that transmit standard transactions in electronic formats are considered covered entities
(Meyer & Schiff, 2004, p. 1). So a dental hygienist, dental office, or other entity providing health
care is considered a “covered entity” and may use and disclose PHI for treatment, payment, and
other activities. Other activities are sometimes referred to as “other operations” and include, for
example, quality assessment. (The terms treatment, payment, and health care operations are
identified at times by the acronym TPO.)
If one can “deidentify” protected health information, that is, make the information inca-
pable of identifying a specific individual, one can disclose this information without consent
or authorization. A patient must also be given written documentation (Notice of Privacy
Protection) regarding how the information will be used and what rights he or she has in
regard to one’s own individual health information. This document must be signed by the
patient and kept in the patient’s file. According to PHI, a patient’s information is to be dis-
closed only to the degree necessary—either to provide treatment or to arrange for payment
(Ring, 2003, p. 26).

EXCEPTIONS If PHI is used for other reasons, these reasons must be disclosed to the patient.
The act ensures that patients’ information is not given or sold to businesses. However, in cases of
emergency, PHI can be released without the patient’s permission. There are situations where the
law requires confidential information to be given without the consent of the individual, such as in
cases of abuse, communicable disease, fraud investigation, and gathering statistical data.
The HIPAA regulates the activities of a business associate, which is a person who per-
forms a function or activity on behalf of a covered entity. Examples of business associates—
or those who create, transmit, receive, or maintain PHI—are vendors, auditors, attorneys,
22 Chapter 2 • Core Values and Additional Ethical Principles

consultants, billing services, transcriptionists, and practice management companies. Covered

entities are required to obtain business associate contracts or written assurances that the busi-
ness associate will safeguard electronic PHI (Meyer & Schiff, 2004, p. 44). Other employees,
such as janitors, whose jobs do not require looking at health information, are not considered
business associates.

PATIENTS’ RIGHTS In addition to the patient’s signing a document that outlines the privacy
practices of how protected information will be used, the patient should also be made aware of
other rights mandated by HIPAA. These patient rights include the ability to access medical
and dental records, to request amendment to medical and dental records, to request an account-
ing of disclosures, and to file a complaint internally (i.e., with the covered initiate) or with the
Office of Civil Rights in the Department of Health and Human Services (Reynolds, 2004). A
patient may also request restricting information that is shared within the organization or confi-
dential communications such as phone calls or mailings. The act also outlines time-frame peri-
ods for responding to patients’ requests and specifies protocols to be followed in that respect.
The requests and responses must be in writing. Patients’ rights according to HIPAA are
outlined in Box 2-3.

FURTHER INFORMATION PROTECTION Finally, to be in compliance with HIPAA, there is a set

of administrative requirements.
• First, there must be a designated privacy officer and a designated contact person. In the
dental office, this could be the same person or two different individuals, such as the office
manager, dentist, dental hygienist, or dental assistant.
• Second, training should be provided to the employees. Recent graduates of dental hygiene
or other health care professions have most likely received basic HIPAA training before
entering internships or other clinical education. However, additional training may be
required for specific protocols of the place of employment.
• Third, there must be safeguards in place to protect PHI.

BOX 2-3
Patients’ HIPAA Rights

• Know how the information will be used

• Access medical and dental records
• Request amendment to medical and dental records
• Request accounting of disclosures
• File a complaint
• Restrict information that is shared
• Protocols for filing and responding to a complaint
Source: The Health Insurance Portability and Accountability Act of 1996
 Chapter 2 • Core Values and Additional Ethical Principles 23

BOX 2-4
Updated Changes in HIPAA

• Business associates are governed by the same requirements as covered entities

• Individuals must be notified if there has been a breach of protected health information
• Patients can request copies of health record in electronic format
• Enforcement and penalties for HIPAA violations are increased
Source: The American Recovery and Reinvestment Act of 2009

STIMULUS PACKAGE The American Recovery and Reinvestment Act of 2009, or stimulus bill,
has made some changes in HIPAA by expanding privacy and security regulations. These updates
to HIPAA are outlined in Box 2-4.
As confidentiality has always been important for the dental hygienists, many of the proto-
cols are already in place. These include taking medical histories in a private area, not speaking
about patients to family or friends, ensuring that other patients or personnel in nearby rooms or
areas do not hear patients’ conversations, shredding paper that contains patient information, and
restricting the use of cellular phones (where others may accidentally overhear) when discussing
patients. Other safeguards include passwords to open specific computer documents that contain
PHI as well as methods to identify and track users and/or to detect activity of electronically
transmitted information. Further information regarding compliance with HIPAA in dental/dental
hygiene practice settings can be obtained from the American Dental Association’s HIPAA
Privacy Kit.

Societal Trust
Another core value that is incorporated into the ADHA Code of Ethics is trust. The code states,
“We value client trust and understand that public trust in our profession is based on our actions
and behavior” (American Dental Hygienists’ Association, 1999, p. 17). The public, as individual
patients and society in general, acknowledges dental hygienists’ possession of specialized
knowledge and skill. It is our ethical duty to ensure that this trust is maintained. However, this
may be difficult when some members of society views health care providers as concerned with
their self-interest more than with the patients’ interests.
Society may form such a view when they suspect that providers act as “gatekeepers” for
“for-profit” companies such as health care management organizations. In fact, many individu-
als believe that the present system has turned providers into employees eager to serve insur-
ance companies and other employers more than they are interested in serving their patients. As
a profession that values and relies on societal trust, dental hygiene must be alert to such mis-
conceptions and must resist any attempt by for-profit organizations to endanger the interests of
patients for financial gain. In the CDHA Code of Ethics, the concept of “trust” is incorporated
in the principles of accountability and professionalism (Canadian Dental Hygienists
Association, 2002).
24 Chapter 2 • Core Values and Additional Ethical Principles

DISCLOSING INFORMATION Societal trust can also be jeopardized if the public perceives a
breach of confidentiality. This is why dental hygienists and other providers should avoid provid-
ing any confidential information about their patients to a third party. If any practical need for
revealing such information to a third party emerges, providers should weigh the benefit and cost
of revealing.
Authorities investigating a crime may request access to records of some patients. In such
situations, protecting the interests of society overrides the right to confidentiality. But there may
be less obvious situations that are more difficult to judge. To deal with situations of this sort, the
provider must examine two questions. First, is the harm of threatening societal trust in the pro-
fession outweighed by the benefit of revealing confidential information? Second, how can the
amount of harm be kept to a minimum when it becomes ethically appropriate to break confi-
dence (Purtilo, 1999, p. 156)?

Nonmaleficence
The core value nonmaleficence means to do no harm to others. Although the principle of doing
no harm may not always seem sufficient for guiding human behavior, it is the most basic element
in morality. In other words, it is a necessary condition for morality. If an action involves harming
a person or a group, it cannot be considered moral. However, as already pointed out, there are sit-
uations that require providing tangible help for other people.

EXAMPLE It is ethical not to interfere with the efforts of the Red Cross that are intended to
relieve a famine in Africa. By not protesting or denouncing such efforts or by merely acknowledg-
ing them, one is demonstrating nonmaleficence. But suppose a person knows that the resources of
the Red Cross and similar organizations are too limited to feed the hundreds of thousands who are
dying of hunger. Would that person be acting morally by doing nothing other than approving of
the goodwill of these organizations? In fact, a person who has a genuine interest in morality would
feel compelled to participate in the effort of shipping or distributing food or donating money for
famine relief. Sometimes by not doing anything, one may be doing harm.
Both beneficence and nonmaleficence are among the principles emphasized by the
Hippocratic oath, although nonmaleficence is stressed as the most basic principle. The oath says,
“primum non nocere,” which means, “First, do no harm.” More recent codes of ethics that are
adopted by health care professions also deal with nonmaleficence as the foundation for medical
ethics. The ADHA Code of Ethics states, “We accept our fundamental obligation to provide serv-
ices in a manner that protects all clients and minimizes harm to them and others involved in their
treatment” (American Dental Hygienists’ Association, 1999, p. 17). Similarly, the IFDH Code of
Ethics ensures that the dental hygienist uses “technology and scientific advances [are] compati-
ble with the safety, dignity and rights of people” (IFDH, 2003, p. 3). In practice, dental hygien-
ists act ethically when they apply all the measures that prevent harm, such as the standard pre-
cautions and thorough debridement. These two examples also demonstrate adherence to
standard of care, which is closely related to nonmaleficence. Standard of care is discussed in
Chapter 5.

Beneficence
The core value beneficence means doing what will benefit a person (e.g., a patient). Most ethical
thinkers feel that doing no harm to other people (nonmaleficence) is not sufficient in all situa-
tions. A person who wants to do what is morally right will often find it necessary to offer active
 Chapter 2 • Core Values and Additional Ethical Principles 25

help to others. As dental hygienists, according to the ADHA Code of Ethics, we have “a primary
role in promoting the well being of individuals and the public by engaging in health
promotion/disease prevention activities” (American Dental Hygienists’ Association, 1999, p. 17).
This is consistent with the Report of the Surgeon General, which emphasizes that “oral health is
essential to the general health and well-being of all Americans and can be achieved by all
Americans” (U.S. Department of Health and Human Services, 2000b, p. 1).
Dental hygienists, as members of a profession that is meant to help the public, have obliga-
tions that extend beyond individual patients to society as a whole. In fact, societies have devel-
oped health care professions, including dental hygiene, to benefit their members. The principle
of beneficence therefore underlies our profession and is also advocated by the CDHA Code of
Ethics (Canadian Dental Hygienists Association, 2002). Furthermore, the IFDH Code of Ethics
suggests: “The dental hygienist’s own personal interest, if in conflict with her/his professional
obligations should b e declared and resolved for the well-being of the client” (International
Federation of Dental Hygienists, 2003, p. 2).

COMMUNITY BENEFICENCE Dental hygienists are becoming more involved in public service
and do not limit their efforts to providing care for private patients. They manage and operate pro-
grams in rural and remote areas and offer care to residents of nursing homes and geriatric facili-
ties. Many hygienists also volunteer in preventive projects that are intended to help members of
their communities, particularly of the less privileged. Fluoridation programs are examples for
these projects. Such contributions to society show that the profession of dental hygiene is prima-
rily guided by the principle of beneficence. Another form of beneficence is pro bono, which is
donating one’s services. A dental hygienist who donates time and skills to a public clinic or who
arranges with the employer to treat those unable to pay is practicing the ethical principle of
beneficence.

Justice
The core value justice can be defined as fairness. In the ADHA Code of Ethics, justice and fair-
ness are considered together as one core value. The code states, “We value justice and support
the fair and equitable distribution of health care resources. We believe all people should have
access to high-quality, affordable oral health care” (American Dental Hygienists’ Association,
1999, p. 17). This position is concerned with individuals and social groups. It emphasizes that
patients should receive the same quality of care regardless of their socioeconomic status, ethnic-
ity, education, or ability to pay. The concept of justice has been discussed in Chapter 1 and will
be discussed further in Chapter 6.

Veracity
The core value veracity means telling the truth. According to the code, “We accept our obligation
to tell the truth and assume that others will do the same. We value self-knowledge and seek truth
and honesty in all relationships” (American Dental Hygienists’ Association, 1999, p. 17).
Truthfulness is a very important component in professional ethics. It is often in the best interest of
the patient to know about his or her condition. Partial disclosure may lead to false hopes or unnec-
essary despair. Incomplete information, such as not telling patients of a less expensive option for
treatment, may also generate financial or practical problems for patients. More important, with-
holding truth from patients can threaten the trust between the patient and provider. As discussed in
Chapter 3, full disclosure of pertinent information is important for informed consent.
26 Chapter 2 • Core Values and Additional Ethical Principles

DECEPTION Occasionally, a health care provider finds that withholding truth would serve the
patient’s interests more than truthfulness. In that case, it may be justified not to be truthful with
the patient, at least temporarily. This kind of “therapeutic deception” is referred to as the
therapeutic privilege. However, this practice should be limited to cases that definitely require it.
Telling a patient that local anesthesia will eliminate any discomfort may be deception if the
patient is not also told that pressure will be felt or that there may be discomfort as the anesthesia
wears off. Both telling a child that dental treatment will not hurt when in fact it may and telling
an adult that the only treatment option is the one covered by insurance when in fact there are
other options are examples of deception. As stated in the IFDH Code of Ethics: “Truthfulness
builds trust” (International Federation of Dental Hygienists, 2003).

ADDITIONAL ETHICAL PRINCIPLES

In addition to core values, other ethical principles may be found in professional codes. These,
like core values, guide the dental hygienist in everyday treatment decisions and access-to-care
issues. Awareness of the role ethical principles play in legislation, resource allocation, and other
initiatives is essential for the dental hygienist. Application of these principles will aid the dental
hygiene profession to continue working toward society’s oral general health

Fidelity
The ethical principle fidelity is closely related to veracity, trust, and confidentiality. Fidelity
means that the health care provider will be faithful to promises and obligations, will abide by
rules and regulations, and will meet all reasonable expectations. In addition, fidelity means that
the health care provider will act as a fiduciary, or a person who will act in the best interest of the
patient. Although fidelity is not listed as a core value in the ADHA Code of Ethics, it is implied
by other explicitly stated principles, such as trust and veracity.

Parentalism/Paternalism
The ethical principles parentalism and paternalism are used synonymously to denote acting like
a parent with the intent to protect or enhance the interests of a person at a time when that person is
unable or unwilling to protect his or her own interests. In such a situation, the autonomy of the
protected person is restricted and his or her freedom of choice ignored or suppressed. The most
acceptable form of paternalism is practicing natural parenthood, where parents do what is in the
best interest of their children. Paternalism becomes a problem when the person on whose behalf
another person is acting is a competent adult. Because competent adults can know what is useful
or harmful for them, they need no other person to decide on their behalf. Indeed, a person who
volunteers to make good decisions for competent adults would be violating that adult’s autonomy.

Case Study Follow-up #2

What are some actions you, as the dental hygienist, could take to help the 15-year old patient
in the case study?

PROVIDER AS PARENT Does it follow that every act of paternalism is wrong? Suppose that a
nurse saw a person in the clinic suffering from low blood pressure and circulatory collapse. He
 Chapter 2 • Core Values and Additional Ethical Principles 27

or she thinks that this patient needs urgent admission to the hospital to save his or her life, but
the patient refuses. It is apparent that his or her refusal is the result of poor circulation, which
causes impaired judgment and mental confusion. Should the nurse make a paternalistic decision
and send the patient to the hospital without delay despite his or her protest? One is inclined to
say yes, but it is difficult to justify forcing people to get treatment when they do not want to.
However, knowing that acute illness frequently impairs the capacity to think soundly seems to
be a good reason for an exceptional violation of autonomy. Furthermore, the nurse is not
infringing on the patient’s autonomy except to preserve the right to life. In normal circum-
stances, the patient would readily accept admission for treatment. So emergencies and tempo-
rary impairment of judgment may validate paternalistic actions on behalf of competent adults.
Most well-intentioned paternalistic acts toward incompetent patients and patients who are con-
sidered minors are justifiable.
In dentistry, a patient may be told what a treatment will be but may not be given a choice.
For example, a dentist may decide what type of material and procedure will be used for a restora-
tion without telling the patient the other options for restorative treatment. By telling the patient
only what the dentist feels the patient needs to know, and by withholding other information, the
dentist has made a paternal decision and has violated the autonomy of the patient.

GOVERNMENT AS PARENT In many situations, paternalism is practiced not by individuals but

by institutions or governments. There are, for example, laws that prohibit the use of recreational
drugs with the intent to protect people—even competent adults—from addiction and consequen-
tial hazards. In most states, the law requires all drivers and passengers to wear seat belts to pro-
tect them from injury in traffic accidents. Both examples reflect paternalistic settings where the
state is acting on behalf of citizens to protect their interests. Yet some competent citizens do not
want that protection and feel that they should be allowed to choose whether they use drugs or
fasten seat belts. The state seems to such individuals an oppressive agency that restricts their
freedom and denies their autonomy. However, the consequences of addiction and serious acci-
dents are not limited to the individuals who choose to harm themselves.

EXAMPLES Society shares the cost incurred by the unsound choices that some of its members
make. It would be justified, at least for this reason, to accept particular forms of institutional
(impersonal) paternalism. In fact, the most obvious form of institutional paternalism in the United
States is the Food and Drug Administration. This agency decides for us which drugs are safe and
which are risky. It limits our freedom of choice but at the same time protects us from potential
harm. In public dental health programs, water fluoridation benefits the public and protects against
caries. However, some citizens feel that this is forcing fluoride on individuals and think that it may
even be detrimental to the health of the public. But the fluoridation program is still implemented to
protect the teeth of most people. Mandatory vaccinations protect the general population. More
recently a new paternalistic regulation has emerged: Smokefree States, where the government—not
the owner or customer of a business—decides that there is no smoking inside a building or within a
given amount of outdoor space in order to prevent diseases caused by secondhand smoke.

Utility
The ethical principle utility, or the usefulness of an action, underlies the theory of utilitarianism
(see Chapter 1). The utility principle encompasses beneficence and nonmaleficence but goes
beyond them. It is needed because neither beneficence nor nonmaleficence alone can solve the
conflicts and competing needs in society.
28 Chapter 2 • Core Values and Additional Ethical Principles

EXAMPLE A group of dental hygienists want to help the elderly poor in rural areas of their
county to get sufficient preventive care. Guided by beneficence, the group considers sending
three hygienists each week to a different remote area to take care of its elderly residents, but the
funds they are able to raise will not cover all the expenses of the project. Some suggest transfer-
ring part of a fund that is intended for serving patients in urban nursing homes. Others disagree
because the needs of urban nursing home residents are equal to those of rural residents. In such a
situation, beneficence alone cannot tell the hygienists whether any group deserves more funds
than the other. It can only tell them that it is morally good to help both groups. Similarly, non-
maleficence would not offer the needed answer. But the utility principle can be a reliable guide
in that context. The utility principle would tell this group of dental hygienists to look for the
action that benefits most nursing home residents.

RESOURCE ALLOCATION The principle of utility is required to assess and rank the needs and
wants of individuals or groups and to help determine social priorities. It can offer answers to
questions about how to allocate resources and how to deal with the various needs of different
sectors of society without causing significant harm to any sector. In effect, the principle imposes
a social duty on us all to use our resources to do as much good as possible. That is, we must do
the most good overall even when this means we are not able to meet all needs in a particular area
(Munson, 1996, p. 36).
When health care providers confront important decisions, they should consider the benefits
and the burdens of each available choice. They should try to realize the greatest benefit and the
least harm for their patients and community. The utility principle is useful not only for making
choices and decisions regarding issues pertaining to groups but also for issues that concern indi-
viduals. For example, this principle can guide us to determine whether the risk of a diagnostic
test outweighs the benefit of the information it provides.

PUBLIC HEALTH Rights of individuals and the needs of the community are apparent in the field
of public health. As dental hygienists expand their roles and the public health component becomes
more vital through access-to-care and advocacy initiatives, they should explore the balance within
the principles of beneficence, nonmaleficence, autonomy, and justice. Box 2-5 outlines the rela-
tionship of ethical principles to public health.

BOX 2-5
Public Health Ethical Principles

Beneficence Protection of individual welfare and promotion of the common welfare

Nonmalficence Weighing risks and potential harms of interveterventions against bene-
fits for individuals and public
Autonomy Individual freedom in political life and personal development
Justice Distribution of resources, maximizing benefits to underserved, and
equality of services
(Coughlin, 2009, p. 29)
 Chapter 2 • Core Values and Additional Ethical Principles 29

Summary
Professional ethical behavior is guided by ethical fidelity. In some situations, these values conflict
principles and core values found in codes of with each other, leading to ethical dilemmas. The
ethics. The Code of Ethics of the ADHA identi- right of patients to autonomy (i.e., to decide for
fies seven core values: autonomy, confidentiality, themselves how they can be treated) should be
societal trust, nonmaleficence, beneficence, jus- respected by health care providers. However, in
tice, and veracity. Similarly, the CDHA’s Code of specific circumstances, this right may be
Ethics has similar principles of beneficence, restricted for the patient’s benefit (e.g., with
autonomy, privacy and confidentiality, accounta- incompetent patients and in emergencies). The
bility, and professionalism. Other ethical princi- U.S. government legislates confidentiality
ples include justified paternalism, utility, and through HIPAA.

Critical Thinking
1. Develop a code of ethics for dental hygiene stu- b. If you were to develop a universal Code of
dents to follow while treating patients and interact- Ethics for dental hygiene students, what ele-
ing with fellow students and faculty. ments would you include and why these
2. Compare the newly developed student code of specifically?
ethics with the ADHA or CDHA Code of Ethics. 4. Refer to the case study at the beginning of the
3. Report on a situation that you encountered in the chapter, how can you (the dental hygienist) main-
clinic where you were forced to make a decision tain the ethical principles of trust and fidelity with
between conflicting actions. Determine which core that patient?
values or ethical principles were involved. 5. As a health care provider, what are your responsi-
a. What ethical principles or core values are sim- bilities according to HIPAA standards?
ilar? Which ones are different?
 CHAPTER 3

Informed Consent

OBJECTIVES
After reading the material in this chapter, you will be able to
■ Discuss the criteria necessary for informed consent.

■ Relate conditions for not obtaining informed consent.

■ Compare the ethical principles found in codes of ethics, informed consent, patients’ bill of

rights, and other documents related to patient care.

KEY TERMS
Assent Patients’ bill of rights Surrogate
Informed consent

INTRODUCTION
A patient’s acceptance (or refusal) of a line of treatment based on the information provided by a
health care provider is informed consent. Patients are becoming more aware of treatment
options as partners in their health care decisions. This chapter will discuss the evolution of
informed consent and the factors that need to be considered for patients to have self-
determination about the health care they receive.

Case Study
You are informing your patient about the details of a crown procedure. She asks you about
the possibility of recurrent decay, pain, or any other complications resulting from the crown
as opposed to having the tooth extracted or a large amalgam restoration. Worried abut her
refusing this recommended treatment option, you tell her that she should not worry because
the dentist is an expert in this procedure.
30
 Chapter 3 • Informed Consent 31

As you read this chapter, consider the following: What information is missing for the
patient to consent to the crown procedure? What ethical principles are involved with the
information you are presenting to this patient?

HISTORICAL BACKGROUND
Simply, there are two sides to informed consent: being informed and giving consent. The
patient is provided sufficient information about his or her condition and the available treat-
ment options. Then the patient is allowed to discuss these options with the provider and to
choose the most suitable treatment alternative. Informed consent allows the patient to make
informed choices regarding treatment or care, and also includes the patient’s right to refuse
treatment.
The notion of informed consent was narrow and restricted until a few decades ago, when
some court decisions triggered interest in reexamining and widening this notion. In the past,
informed consent consisted of a patient signing, before surgery, a form stating the name of the
operation and the risks associated with it. The purpose of these forms was twofold:
• Telling the patient about the nature of the procedure and its advantages and risks
• Ensuring legal protection for the practitioner if one of the mentioned risks occurs.
That context covered informed consent requirements at that time. The practitioner was act-
ing ethically by doing what was right for the patient (i.e., what he or she considered to be in the
best interest of the patient).
The concept of informed consent is not merely obtaining documented consent from a
patient. Rather, it is considered a well-intended discussion between a provider and a patient,
informing the patient about every relevant aspect in the proposed procedure, the alternative
procedures, and the points that the patient should consider while opting for a particular
procedure. The provider is no longer a paternalistic authority who decides what is best for
the patient.

Giving Information
At first thought, the concept of informed consent may seem easy to understand: a practitioner
tells the patient what will be performed and the patient agrees. But other aspects need to be con-
sidered. The following are only a few examples of countless questions surrounding informed
consent. In fact, the concept of informed consent is multidimensional and involves substantial
legal (e.g., negligence) and moral (e.g., patient’s autonomy) issues.
• To what extent should the patient be informed?
• Should the explanations offered to patients involve technical details?
• Should the uncommon adverse effects of a therapeutic modality be specified?
• Would a practitioner be legally protected if he or she warns patients that the probability of
the elected procedure causing severe bleeding is only 1 in 300 and then a patient happens
to bleed excessively from that procedure?
• Could the failure of obtaining an informed consent automatically free the practitioner of
legal liability if the patient’s health deteriorates because of his or her decision to withhold
treatment?
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