What does our profession have to do with Königsberg? This, dear readers, you might be wondering about. You might even get the feeling that Königsberg is a place of ethics.
Throughout a large part of the 20th century, questions concerning ethics rarely touched on the field of medicine and hardly ever on the field of dentistry. This has changed fundamentally. Expectations have grown as more and more medical progress has been made. At times, new technologies have had such an impact on our lives that ethical conflicts have arisen. The resulting discourses in medicine have considered preimplantation genetic diagnosis, organ transplantation, euthanasia, or stem cell research. Such discourse is now also occurring within dentistry. The dimension of the problems might be smaller, yet the German Dental Association has felt compelled to found an ethics committee.
In times when patients would visit the dentist only when they were already in pain, the ethos of the profession, expressed through the Hippocratic oath, justified any type of action. For the past 2,500 years, this oath has committed doctors to providing assistance, and for centuries, medical care amounted to nothing more than this. Thus, a dentist acted on behalf of the well-being of the patient—salus aegroti suprema lex—without restrictions. Scientists call this paternalism.
Times have changed. Dental checkups have become a routine practice. Oral prophylaxis and the prevention of pain have become top priority. In addition, full advantage of technologic progress in the field of restorations has been taken, more and more frequently with the help of implants. The fulfillment of esthetic desires has gone to such lengths that the dentist is seen as a type of wellness provider in some places. This opens up numerous financial opportunities that, along with respective marketing strategies, have changed the image of dentists. At a time when we have been presented with a whole new range of possible professional behavior, the introduction of an ethical standard of values seems appropriate. This is all the more important since the occurrence of shortcomings that have distorted the image of our profession in the public eye.
Therefore, the ethical concept that lies behind paternalism no longer does today’s reality justice. Of all the different modern theories that address ethics in dentistry, it seems as if Beauchamp and Childress’s Principles of Biomedical Ethics1 is the appropriate way of dealing with the current situation, all the more so as they are independent of religious and ideologic beliefs. The four principles are: (1) respect for autonomy, the patient’s right to self-determination; (2) nonmaleficence, to do no harm; (3) beneficence, the well-being of the patient comes first; and (4) justice, the obligation to treat all patients fairly and justly.
Let me now name a few routine occasions in everyday life that demonstrate that ethically questionable actions are sometimes imminent. When it comes to overdenture provision, edentulous patients are often being recommended four interforaminal implants, although it has long been known that two are sufficient.
How many times during scientific lectures have we been told that the patient insisted on this specific measure. As listeners, couldn’t we have actually expected a simpler and more economic solution? Isn’t the patient often simply being given the impression that a more complex and thereby more expensive procedure is best? Given that speakers addressing an expert
audience feel the need to explain themselves and use the patient’s request as the reason for the choice of treatment, it is clear that the aforementioned procedure does not represent the most sensible approach.
As regards science, problematic situations having to do with certain constraints young scientists are under can also occur. This has to do with the need to produce publications of clinical content based on a relevant statistical number.
The pressure to complete the required operation catalog can also dictate the choice of treatment. How many implantologists have actually received an autogenous bone transplant, which is the gold standard (if this rather heretical question may even be asked)? This is about following the principles of fairness and confining oneself to measures you would agree to yourself.
Acting according to ethical principles also means having the grace to refer patients to other places when certain services can better be provided elsewhere. In the long term, this would also mean receiving patient referrals within one’s own area of expertise. It is possible for vanity to get in the way of professional cooperation.
Of course, a dentist with an office and staff is subjected to financial restraints and can therefore face a conflict situation. However, if we let money dictate treatment ethics, there will be less patient trust in dentists in the future. As a result, the entire profession will ultimately suffer.
To come full circle, dear readers, let’s come back to Königsberg. This old German city, which was in what was originally Eastern Prussia, is now called Kaliningrad and is a part of Russia. There, 225 years ago, Immanuel Kant developed the theory of the categorical imperative, in which he stated an ethical principle: Act so that the principle behind your action might safely be made into a universal law. Meaning: Let your decisions be righteous and good. After all has been said and done, if we internalize Kant´s request to do the objective good for the patient, we can easily dispense with various theories and sometimes contradictory approaches to treatment. For our patients, this means that what is best for them doesn’t necessarily have to be what is most expensive.
Siegfried M. Heckmann, PD, Dr Med Dent, Dr Phil
School of Dental Medicine
University of Erlangen-Nuremberg
1. Groß D, Groß K, Schäfer G. Ethik in der Zahnheilkunde—eine Einführung mit Progress-Test. Teil 1: Allgemeine Grundlagen. Deutsche Zahnärztliche Zeitschrift 2011;