Consent in dentistry: ethical and deontological issues
- 1Forensic Science Department, University of Brescia, Centre of Bioethics Research (with contribution of Fondazione Poliambulanza), Brescia, Italy
- 2Dental School, University of Brescia, Brescia, Italy
- Correspondence to Dr Paola Delbon, Forensic Science Department, University of Brescia, Centre of Bioethics Research (with contribution of Fondazione Poliambulanza), 25123, Brescia, Italy;
- Received 6 June 2012
- Accepted 12 September 2012
- Published Online First 12 October 2012
In Italy, consent for health treatment, aside from being an ethical and deontological obligation, constitutes an essential requirement for any medical treatment according to articles 13 and 32 of the National Constitution and also in accordance with the Council of Europe's ‘Convention on Human Rights and Biomedicine’. An essential requirement for the validity of consent is that clear, exhaustive and adequate information be provided to the patient himself: the practice of informed consent is a communicative relationship in which the patient can express doubts, perplexities and clarification requests to the dentist. Furthermore, dental treatment has specific peculiarities: the relationship between dentistry and aesthetics, the concomitant presence of pathologies requiring different treatments, the elongated care process and the establishment of a trustworthy relationship and familiarity with the patient represent important aspects in the configuration of the dentist-patient relationship and in the process of acquiring informed consent. The dentist must offer correct information on diagnosis, prognosis, the therapeutic perspective and the likely consequences of therapy, alternative therapy and refusal of therapy, as well as eventual commitments for the period after treatment. Particular consideration must be given to minors and patients of unsound mind: the dentist's approach to these patients needs to be clear and appropriate to the person's age and understanding ability, even if the decisional power for sanitary treatment may be in the hands of a third person.
Dental practice is directed by the same principles that regulate the doctor-patient relationship: the practice of dentistry with a patient requires obtaining the patient's consent and delivering appropriate information. The right of patients to make decisions about their healthcare has been enshrined in legal statements: in Italy the National Constitution establishes that personal liberty is inviolable and that no one may be obliged to undergo any given health treatment except under the provisions of the law (Section 13 and 32).
In addition, the Charter of fundamental rights of the European Union1 and the Council of Europe's ‘Convention on human rights and biomedicine’2 establish the general rule of free and informed consent in the health field.
In particular, the Explanatory Report to the Convention3 underlines that ‘This rule makes clear patients’ autonomy in their relationship with healthcare professionals and restrains the paternalist approaches which might ignore the wish of the patient’.
This rule is an important application of the principle of Respect of Autonomy: ‘to respect an autonomous agent is, at a minimum, to acknowledge that person's right to hold views, to make choices and to take actions based on personal values and beliefs’.4
Furthermore, the Italian Code of medical ethics5 and the Code of Ethics for Dentists in the European Union6 establish that the dentist must give the patient the most proper information about diagnosis, prognosis, perspectives and possible diagnostic-therapeutic alternatives and about the foreseen consequences of choices and must enable the patient to give informed consent for the treatment that is to be carried out.
The Dental Ethics Manual by the FDI World Dental Federation7 underlines that ‘A necessary condition for informed consent is good communication between dentist and patient’ and instructs that there are three major obstacles to good dentist-patient communication: differences of language and of culture (because of different cultural understandings of the nature and causes of illness, patients may not understand the diagnosis and treatment options provided by dentists; moreover, what is considered a disfigurement in one culture may be a sign of beauty in another) and patient speech impairment during treatment (because of this possibility, patients should be fully informed, in advance, of all relevant information about their treatment, and dentists should take steps to facilitate two-way communication during treatment).
Information and consent in dentistry: particular aspects
Considering that the practice of dentistry is encompassed by the general ethical standards governing the patient-doctor relationship, a number of dental activities, especially those for aesthetic purposes, deserve special bioethical attention: the face, and above all the mouth, ‘represents a primary element of approach and exchange with the world of other people, but primarily the only image of ourselves… that we carry inside us as the symbol of our identity able to condition us in our relationship with others’. If it is the case that ‘some treatment… even though being scientifically appropriate, could harm essential personal values, such as to represent a source of even serious malaise to the point of causing serious existential anxiety’ (eg, a case in which the decrease in aesthetic efficiency may be a necessary sacrifice in obtaining better masticatory function), it is also the case that ‘every possible change—even one of betterment—of our appearance or of its dynamism that does not correspond with the scheme of ourselves can be the source of great malaise’.8
Information thus becomes essential, especially in relation to treatments that affect not only the therapeutic programme but in particular the aesthetic level9: ‘the process of obtaining informed consent does not consist simply of presentation of information. It should reflect the dentist's effort to educate and discuss the findings with patient…’.10
New technologies in image processing also present professionals with new ethical issues. Orthodontists do not recommend computer morphing to convince the patient to accept a treatment; they consider it a suggestive tool for clarifying some aspects of changes in facial appearance. Despite intentions, however, today we can be confronted with a patient requesting a second opinion on a treatment plan after having already received morphing documentation from a previous consultant. We cannot avoid answering a patient's questions about whether our proposed treatment will achieve the same result or not, so morphing could be part of the conversation in some consent procedures. In most cases, we can say that morphing is highly influenced by soft tissue drape because of head posture, so the discussion can be limited to the previous consultant's indications and evaluations.
Some conditions encourage the establishment of a trust relationship between patient and dentist: ‘the fact that the dental appointments and relative treatment take place in the dentist's surgery, that they can go on for months or years … can foster the establishing of a friendly relationship and even familiarity born from previous treatment, or sometimes from a custom that is handed down from relatives or friends being treated by the same dentist’.8
This may involve the risk of paternalism, ‘an antiquated manner of interacting with autonomous people and is inconsistent with the virtue of respect for patients’ autonomy’.10
Within the field of orthodontics, where both physiological-functional and aesthetic objectives are closely linked in assessing the appropriateness of a treatment, the orthodontist must consider other reference parameters—such as subjective symptoms and social acceptability—that highlight the central role of the interview with the patient where the healthcare professional must pay particular attention to the psychological, social and cultural factors that characterise the relationship of care.11 The dentist should strive to have clear understanding of the expectations of the patient from each proposed procedure, which enhances the process of coming to the shared decision.
The frequent involvement of minor patients in this discipline also makes it crucial to establish a trust relationship among patients, their parents and dentists because of the protracted duration of treatment and the likely occurrence of difficulties that might discourage young patients; a favourable treatment outcome is much more likely when the patient and parents effectively endorse the recommended therapeutic prescriptions. Sufficient information will also include discussion of both the patient's and the parents’ duties regarding the use and maintenance of orthodontic appliances and regarding oral hygiene.
Even with implants, the dentist, keeping in mind the expectations of the patient and his health, must highlight all aspects of the treatment: risks, complications, viable alternatives, timing of finishing and completion of therapy,6 likelihood of successful intervention and the measures the patient needs to take when using the prosthesis to ensure the favourable completion of treatment.12
Information and consent in dentistry: particular situations
Many patients (eg, children and incompetent adults) require substitute decision-makers: ‘dentists have the same duty to provide all the information the substitute decision-makers need to make their decisions’.13
Children, exposed to dental care from an early age but not legally able to give consent to treatment, ‘should be consulted, enabling them to participate in the decision making process’; in particular ‘providing information, ensuring the adequacy of this information, checking that the explanation has been understood and the opportunity to make an informed choice has been created’.14
The ‘Convention on human rights and biomedicine’ establishes that ‘The opinion of the minor shall be taken into consideration as an increasingly determining factor in proportion to his or her age and degree of maturity’ and that, in the case of incompetent adult, ‘the individual concerned shall as far as possible take part in the authorisation procedure’ (Section 6).
In addition, the American Academy of Paediatric Dentistry15 stresses that ‘a child's cognitive development will dictate the level and amount of information interchange that can take place’ and that ‘…the successful completion of diagnostic and therapeutic services is viewed as a partnership of dentist, parent and child’.
In a trusting dentist-patient relationship, the dentist must offer appropriate information about all aspects of the treatment and commitments after treatment and should ensure that the patient understands all the information.
If informed consent is a legal requirement for every dental procedure, the shared decision-making process is first of all a requirement of good dental practice: informing the patient and making him an autonomous agent is an integral part of health protection, ethical and deontological duty of every dentist: the ethical principle of respect of Autonomy finds its main application when the informed patient takes part in the decision-making process, in proportion to his/ her age and capacity to understand.
In Italy, the National Bioethics Committee16 underlines that information ‘is aimed … at placing a subject… in the condition to carry out his or her rights in a correct way and hence to express a will that is in fact his or her own’.
In summary, ‘it is not the written word but the interaction between dentist and patient … the foundation of informed consent’ that ‘should not be looked on as a legal necessity and a duty, but rather as a virtue of good dental practice’17 and, according to us, a knowing synthesis of kindness of practitioners to take ‘care’ of understanding of the patient without prejudice, tailoring to adequately inform every unique person.
Contributors AC: Study concepts, Guarantor of integrity of entire study. PD: Literature search, Manuscript preparation and editing. LL: Manuscript revision. CP: Study design, Final approval of the version to be published.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.