A principled approach

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					                                                                                       July 2005

A principled approach
                     David Corless-Smith reviews the GDC’s latest ethical

As from June 1 all dental professionals –           This guidance replaces the previous
dentists, dental hygienists and dental              guidance Maintaining Standards, although
therapists – have been governed in their            it is not retrospective in effect so that
working lives by new ethical guidelines laid        complaints in relation to misconduct that
down by the General Dental Council. As              took place before June 1 will be dealt with
the regulatory body, the GDC is                     by reference to Maintaining Standards.
responsible for the protection of dental
patients by setting appropriate standards of        The first observation to be made of the
practice and conduct for dental                     new guidance is how svelte it is – three
professionals. In this role as maintainer of        documents comprising some 18 short
professional standards, the GDC – in                pages against Maintaining Standards
common will all professional regulatory             rather thicker 90 pages. The scope of the
bodies – has an obligation to set out, in           topics covered by the new guidance is
sufficient detail, the standards of ethical         considerably narrower than its
behaviour expected of those licensed to             predecessor. The new guidance appears
practice within the profession. Such                to have eschewed the previous rather
standards will, of course, evolve with the          prescriptive advice relating to particular
changing ethics of society and, in                  aspects of dental practice in favour of a
particular, society’s expectations of               distillation of ethical dental practice into six
healthcare professionals.                           overreaching principles (except rather
                                                    curiously, in respect of the provision of
The GDC has issued its latest ethical               dental treatment under general
guidance at a time when the competence              anaesthesia and conscious sedation,
of the regulatory bodies of healthcare              which retains its own specific guidance
professions to maintain standards within            annexed to the main standards guidance).
their professions is coming under particular
scrutiny. The new guidance presently                Further, the guidelines apply in their
comprises three documents. The core                 entirety to all registered dental
guidance is set out in a document entitled          professionals, now termed registrants who
Standards for dental professionals. This is         presently comprise dentists, dental
supplemented by further guidance on the             hygienists and dental therapists – as
issues of consent and confidentiality               opposed to the previous distinct and
contained within separate documents                 separate guidance to dentists, hygienists
which are entitled Patient Consent and              and therapists. It is envisaged that the
Principles of Confidentiality respectively. A       guidance will apply equally to dental
fourth document dealing with teamwork               nurses and dental technicians as soon as
issues which is entitled Guidance for the           these professionals come under the GDC’s
dental team is due to be published in               disciplinary jurisdiction. This is in keeping
October.                                            with the new emphasis on team working
                                                    within the practice of dentistry.

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The guidance now requires dental                       This scenario, although probably familiar to
professionals to adopt and apply the                   many dentists, is not expressly addressed
following six principles in their practice of          in the new Standards Guidance (or indeed
dentistry.                                             any previous ethical guidance provided by
• To put patients’ interest first and act to           the GDC). However, the GDC’s exposition
     protect them                                      of the principles underpinning the guidance
• To respect patients’ dignity and                     can assist the dental professional’s ethical
     choices                                           reasoning in this and other ethical
• To protect the confidentiality of                    dilemmas not specifically advised upon
     patients’ information                             and, is therefore a very welcome inclusion
• To cooperate with other team
     members and colleagues in the                     The question to be explored over this
     interests of patients                             series of four articles is whether the new
• To maintain their professional                       guidance has struck the right balance
     knowledge and competence                          between sufficiency of explanation of the
• To be trustworthy                                    underlying ethical principles and adequate
                                                       detail in the practical applications of the
To attempt to categorise the ethical                   guidance offered.
principles underlying dentistry is a daring
task. Traditionally codes of profession                In response to this enquiry, the GDC might
conduct have contained a prescriptive                  respond that it would be impossible to
statement of behaviour to be followed in               provide sensible ethical guidance for the
specific situations frequently encountered             myriad of scenarios that a dental
in professional practice. Maintaining                  professional could conceivably face in
standards followed this format. Rarely do              clinical practice. While it must be readily
such professional codes contain any                    accepted that any code of professional
analysis of (or indeed even reference to)              practice could not hope to included every
the underlying ethical principles that seek            possible facet of practice which has an
to justify or explain the guidance given.              ethical component that is not to say that
Again Maintaining Standards did not.                   such a code must not aspire to be as
                                                       comprehensive and practical a guide as is
Of course to be of any use in the real world           possible to the application of ethical
of professional practice, a code of conduct            principles to professional practice. If a
must descend into practical advice and                 regulatory body is to enforce a satisfactory
judgments in relation to specific scenarios.           standard of conduct for a professional
However, there will be many professional               person then it is incumbent upon it to
scenarios for which the correct course of              provide transparent and comprehensive
action has not been prescribed by a code               guidance upon the standards expected. In
of conduct and which produces an ethical               this way professional misconduct can, to
dilemma that needs to be resolved by the               an extent, become avoidable and greater
professional. An understanding of the                  protection thereby afforded to the clients of
conflicting ethical principles involved in a           professional services.
particular scenario helps the professional
to assess the relative priority of the                 The six principles identified as the
applicable moral principles and provides a             fundamental principles of dental practice
reasoned approach to resolving the ethical             by the GDC make an interesting selection.
problem within that situation. For example,            The first principle of putting a patient’s
when examining a new patient a dentist                 interests first and protecting them might be
identifies substandard dental work. Does               viewed as either two separate principles or
the dentist’s ethical duty of fidelity and trust       a single principle. The principle of acting in
to the patient demand full disclosure to the           the patient’s best interests or, put another
patient of the poor work or does the                   way, acting for the benefit of the patient is
dentist’s bond of loyalty to professional              known as the ethical principle of
colleagues require that he does not report             ‘beneficience’ and has long been accorded
the substandard work to the patient? A                 a special status by the caring professions
reasoned consideration of the underlying               such as medicine and dentistry. The duty
conflicting ethical duties owed to the                 to benefit a patient is accompanied by the
patient and to colleagues can enable the               duty to do no harm or to protect the patient,
dentist to resolve the dilemma.                        which is known as the principle of ‘non-
                                                       maleficience’. The principles of

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‘beneficence’ and maleficence’ can be                The fifth principle of maintaining
looked upon as a single principle with the           professional knowledge and competence
promotion of a patient’s well being at one           appears to be a practical application of the
end of a continuum and the prevention of             first and second principles rather that a
harm at the other end.                               separate ethical principle in its own right.

The second principle of respecting a                 The sixth principle of trustworthiness is a
patient’s dignity and choices is the ethical         fundamental ethical principle but as with
principle of respecting a person’s                   the third principle is an aspect of the
autonomy or right to control their own lives         second principle of respecting people.
and make their own decisions. This
principle has gained primacy over the first          Each principle is expanded upon in a
principle within dental ethics over the past         separate section within the GCD guidance
two decades and this is acknowledged by              and examples of both generic and specific
the prominence of this principle throughout          applications of each principle are given.
the guidance. The question as to who
should judge a patient’s best interests –            The six individual principles together with
the patient or the dentist – is now firmly           their applications will be discussed in some
answered to be the patient’s decision.               detail in the subsequent articles in this
                                                     four-part series. The next article will deal
The third principle of protecting the                with the principles of putting patient’s
confidentiality of a patient’s information is        interests first and respecting patient’s
based on the obligations of fidelity and             dignity and choices.
honesty, which are aspects of the second
principle of respecting people.
                                                     Initially published in The Dentist
The fourth principle of co-operating with            July/August 2005 edition
other team members in the interests of the
patients is a more curious choice of a
fundamental ethical principle. The ultimate
objective of this principle, namely to benefit
the patient appears to be a repetition of the
first principle. The distinction between the
two principles seems to be that the first
principle represents the individual
obligation of the dental professional to
benefit the patient against the team
obligation of the fourth principle. It is
doubtful whether these amount to, two
fundamentally different ethical principles.

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