Dental, Medical and Nursing Ethics: Comparison and Contrast

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Dental, Medical and Nursing EthicsComparison
and Contrast

• John R. Williams, Ph.D.
• Adjunct Professor
• Dept. of Philosophy, Carleton University
• Dept. of Medicine, University of Ottawa
• Centre for Health Care Ethics
• Lakehead University
• 13 June 2007

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Outline of Presentation

• Sources
• Typical cases
• Similarities
• Differences
• Potential conflicts
• Resolving the conflicts

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Sources

• Canadian Dental Association Code of Ethics
  (www.cda-adc.ca)
• Canadian Medical Association Code of Ethics
  (www.cma.ca)
• Canadian Nurses Association Code of Ethics for
  Registered Nurses (www.cna-nurses.ca/cna)
• World Medical Association Medical Ethics Manual
  (www.wma.net)
• FDI-World Dental Association Dental Ethics
  Manual (Fall 2007 - www.fdiworldental.org/)
• Michael Yeo and Anne Moorhouse Concepts and
  Cases in Nursing Ethics, Broadview Press 1996

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Dental Ethics Case

• Dr. A is one of only two dentists in her
  community. Between them they have just managed to
  provide basic oral care to the population.
  Recently her colleague has changed his practice
  to focus on technically and aesthetically
  advanced services that only adequately insured or
  middle and upper class patients can afford. As a
  result, Dr. A is overwhelmed by patients
  requiring basic care. She is reluctant to ration
  her services but feels that she has no choice.
  She wonders what is the fairest way to do so by
  favouring her previous patients over those of her
  colleague by giving priority to emergency cases
  by establishing a waiting list so that all will
  get treated eventually or by some other way.

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Medical Ethics Case

• Dr. B is becoming increasingly frustrated with
  patients who come to him either before or after
  consulting another health practitioner for the
  same ailment. He considers this to be a waste of
  health resources as well as counter-productive
  for the health of the patients. He decides to
  tell these patients that he will no longer treat
  them if they continue to see other practitioners
  for the same ailment. He intends to approach his
  medical association to lobby the government to
  prevent this form of misallocation of health care
  resources.

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Nursing Ethics Case

• Dr. C is the Vice-President of Nursing in an
  urban teaching hospital. Last year, the hospital
  budget was reduced by five per cent. Dr. C worked
  with nursing managers in the various units and
  with other administrators to find creative
  solutions to the hospitals budget problem.
  Lay-offs were thus avoided but nursing positions
  lost due to attrition were not filled. Because of
  the increased demands on the remaining nurses,
  they are advocating that beds be closed, despite
  the shortage of beds in the area. Dr. C has to
  decide whether to recommend closing beds or
  leaving them open and risk alienating the nurses
  and compromising the quality and safety of care.

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Similarities - 1

• Each case deals with allocation of scarce health
  care resources
• Different settings, problems, roles and
  responsibilities
• Same concern for justice providing fair
  treatment to patients (actual and potential) and
  to providers (including themselves)

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Similarities - 2

• First responsibility is the well-being of
  patients
• CDA Code of Ethics, article 1 As a primary
  health care provider, a dentist's first
  responsibility is to the patient.
• CMA Code of Ethics, article 1 Consider first
  the well-being of the patient.
• CNA Code of Ethics for Registered Nurses
  Nurses must provide care directed first and
  foremost toward the health and well-being of the
  person, family or community in their care.

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Similarities - 3

• Importance of respect for patients and their
  autonomy - informed consent/choice and
  confidentiality
• Insistence on achieving and maintaining provider
  competence
• Obligation to provide emergency care
• Need to balance providers professional autonomy
  with team approach to patient care
• Recognition of institutional restraints on
  ethical behaviour (political, administrative,
  commercial)

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Differences - 1

• Previously greater than at present
• Little attention to dental ethics until recently
• Medical ethics traditionally focussed almost
  exclusively on the individual patient-physician
  relationship
• Nursing ethics emphasised caring and service
• All this has changed, but other differences
  remain.

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Differences - 2

• Regarding the balance between professional and
  business values
• Dentists tend to privilege business values
  (understandable because of lack of public
  funding)
• Physicians are conflicted (wide spectrum from
  cosmetic plastic surgery to public health)
• Nurses privilege professional values

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Differences - 2

• Example treating patients with inadequate
  health insurance
• - Nothing in CDA Code of Ethics about this
  (either for individual dentists or the profession
  as a whole)
• - CMA Code In determining professional fees to
  patients for non-insured services, consider both
  the nature of the service provided and the
  ability of the patient to pay, and be prepared to
  discuss the fee with the patient.
• - CNA Code Nurses uphold principles of equity
  and fairness to assist persons in receiving a
  share of health services and resources
  proportionate to their needs and in promoting
  social justice.

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Differences - 3

• Relations with patients
• Dentists have to be concerned about the financial
  resources of their patients.
• The patient-physician relationship is
  increasingly fragmented, especially in hospitals.
• Nurses want to do more for patients but are
  prevented by institutional forces.

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Potential Conflicts - Roles

• Very little overlap between dentists and
  physicians or nurses
• Shifting boundaries between medicine and nursing
  (nurse practitioners, nurse prescribing,
  midwifery, etc.)
• Evolving paradigms of patient care relating
  physiological to psycho-social aspects

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Potential Conflicts - Authority

• Generally good relationships between dentists and
  physicians, and between dentists and nurses
• Mixed views among physicians regarding their
  authority over nurses and other health care
  providers (N.B. liability)
• Mixed views among nurses regarding their
  authority vis-à-vis other health care providers
  (N.B. experience and expertise)

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Potential Conflicts - Accountability

• All are accountable to patients, to other members
  of their profession and to their regulatory
  authorities
• No mention of accountability to other health
  providers in any of the Codes of Ethics
• Compare the WMA International Code of Medical
  Ethics (2006) A physician shall behave towards
  colleagues as he/she would have them behave
  towards him/her.

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Resolving Conflicts 1

• CMA, CNA, CPhA Joint Statement on Scopes of
  Practice
• - Policy decisions taken in this area must put
  patients first.
• - They should be grounded in principles that
  reflect a commitment to professionalism, lifelong
  learning and patient safety.
• - There is need for legislative and regulatory
  changes to support evolving scopes of practice.
• - Health professionals must be involved in
  decision-making processes in this area.

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Joint Statement on Scopes of Practice

• Principles
• Focus
• Scopes of practice statements should promote
  safe, ethical, high-quality care that responds to
  the needs of patients and the public in a timely
  manner, is affordable and is provided by
  competent health care providers.
• Flexibility
• A flexible approach is required that enables
  providers to practise to the extent of their
  education, training, skills, knowledge,
  experience, competence and judgment while being
  responsive to the needs of patients and the
  public.

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Joint Statement on Scopes of Practice

• Principles
• Collaboration and cooperation
• In order to support interdisciplinary approaches
  to patient care and good health outcomes,
  physicians, nurses and pharmacists engage in
  collaborative and cooperative practice with other
  health care providers who are qualified and
  appropriately trained and who use, wherever
  possible, an evidence based approach. Good
  communication is essential to collaboration and
  cooperation.

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Joint Statement on Scopes of Practice

• Principles
• Coordination
• A qualified health care provider should
  coordinate individual patient care.
• Patient choice
• Scopes of practice should take into account
  patients' choice of health care provider.

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Resolving Conflicts -2

• CMA, CNA, CHA, CHAC Joint Statement on
  Preventing and Resolving Ethical Conflicts
  Involving Health Care Providers and Persons
  Receiving Care
• - Disagreements among health care providers
  about the goals of care and treatment or the
  means of achieving those goals should be
  clarified and resolved by the members of the
  health care team so as not to compromise their
  relationship with the person receiving care.
  Disagreements between health care providers and
  administrators with regard to the allocation of
  resources should be resolved within the facility
  or agency and not be debated in the presence of
  the person receiving care.

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Conclusions

• Dentistry, medicine and nursing are inherently
  ethical activities.
• Their ethical principles and responsibilities are
  similar but not identical.
• The differences can give rise to conflicts that
  must be resolved in the interests of patients, of
  society and of the professionals themselves.

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Thank You!!!