Journal of the American College of Dentists

Students’ Views on Ethics
20
I feel Mr. E does not understand
the gravity of his condition. Not only is
Mr. E neglecting his oral health, but he
has informed me that he does not
regularly see a physician and seldom
takes medication for any ailments.
Despite his actions, I believe that Mr. E’s
credentials are genuine and that he is
quite an intelligent man.
In the past year, Mr. E has come in
for several treatment-planning sessions.
As he has called to discuss his painful
teeth, I have made appointments for him
to have them extracted. It has been a
long and frustrating process convincing
Mr. E to extract his remaining teeth after
he recently invested so much time and
money into crowns and veneers placed
by previous University of Washington
dental students.
Washington State Laws
RCW 74.34 describes the responsibility
of dentists and others to report possible
abuse of vulnerable adults. Although
Mr. E lives on his own, I am concerned
that he may not be completely capable
of caring for himself. Mr. E’s diet consists
primarily of candy, ice cream, canned
soups, and alcohol. Mr. E does not
want to ask his son for help in matters
regarding his health care. I firmly
believe that Mr. E is a vulnerable adult
and is currently living in a state of
“self-neglect,” compromising his health
by masking his dental problems with
sleeping medications and alcohol.
Community members, regardless of age,
make poor decisions regarding their
health care. When is it the dentist’s
responsibility to alert social services
when an elder falls into this category?
RCW 18.130.180, Section 4 describes
incompetence, negligence, or malpractice
which results in injury to a patient
or which creates an unreasonable risk
that a patient may be harmed. Mr. E’s
previous student dentist may have been
demonstrating negligence or incompetence
if he or she had performed the
extensive dental work on Mr. E knowing
that he is not fully capable of properly
managing his oral hygiene. A dentist
must be aware of a patient’s ability to
maintain dental restorations. Mr. E’s poor
oral hygiene, diet, vision, and manual
dexterity should have been taken into
consideration before the previous dentist
placed porcelain crowns and veneers.
Had these circumstances been evident
during the previous treatments, Mr. E’s
prior dental student may be seen as
creating unreasonable health risks to
Mr. E, thus demonstrating negligence.
RCW 18.130.180, Section 16 describes
misconduct resulting in promotion for
personal gain of any unnecessary or
inefficacious drug, device, treatment,
procedure, or service. The previous
dental student would have violated this
section if the treatment for Mr. E was
completed in order to satisfy clinical
requirements while disregarding Mr. E’s
need or indication for such treatment.
ADA Code of Ethics
Patient Autonomy: Mr. E’s thought
process is different from what I would
want for myself if I were in his position.
However, Mr. E seems to know what he
does and does not want. I have spent
many hours in treatment-planning
sessions talking to him, explaining his
needs and presenting him with possible
treatment options. We have discussed
the possible outcomes and associated
costs of various treatments. The time I
have spent with Mr. E has allowed him
to accept that he needs a comprehensive
treatment plan that addresses his whole
mouth while preserving his general
health. Such a plan will avoid trying to
save his remaining teeth with root canals,
buildups, and new crowns while he is
unable to maintain proper oral hygiene.
Mr. E’s ability to provide informed
consent is uncertain. We spent many
appointments reviewing the hopeless
prognosis for his teeth and his need for
a denture. He frequently leaves appointments
saying, “Well, you’ve surely given
me a lot to think about.” He calls several
days later asking about crowns and the
possibility for dental treatment other
than what we had discussed. Being that
Mr. E has had such extensive dental
treatment in the past, he may simply be
upset that he must extract his teeth and
is trying to avoid this plan.
In order to abide by the principle
of confidentiality (Section 1B) I have
avoided discussing the complications of
Mr. E’s case with the gentleman who
occasionally brings Mr. E to his appointments.
This gentleman’s daughter is a
nurse and has called the dental school
in the past to inquire about Mr. E’s care.
She did not get in contact with me;
however, Mr. E may allow me to talk
with her to coordinate the treatment
presentation appointment so that he can
be properly cared for while he is healing
from oral surgery.
When does a dentist decide if a person
is unfit to make decisions for himself or
herself? Just because someone is elderly,
should his or her ability to make mistakes
and poor judgment calls be limited?
Younger adults make poor decisions
constantly; however, they are allowed
autonomy to follow their own desires.
Nonmaleficence: It may be easy to
assume that the student dentist responsible
for the expensive dental treatment
Mr. E has had in the past was being
negligent and causing harm to Mr. E.
Alternatively, the patient may have been
more diligent about oral hygiene in the
2011 Volume 78, Number 4