Journal of the American College of Dentists

Students’ Views on Ethics
38
believe that dental problems were readily
treated with conventional imaging to a
successful degree. For example, simple
alternatives to the CBCT include a
panoramic x-ray and lateral cephalograms
taken at various stages of treatment.
The only other possible alternative is
refraining from all x- ray imaging and
treatment altogether. Obviously each
option has different ethical implications
with respect to autonomy, beneficence,
and maleficence. The patient receives
no benefits from no treatment, but may
receive partial benefit from older x-ray
devices. It is also imperative to ask
whether the dentist is confident in his
or her ability to render treatment given
the compromises the patient makes. A
dentist can determine moral responsibility
by weighing solely the consequences
of actions, as the theory of consequentialism
suggests, deeming actions as
morally right only if the consequences
are more favorable than they are unfavorable.
Then, it is possible that certain
alternatives, such as using a panoramic
x-ray to place an implant into a severe
lingual bony undercut, are too grave in
prognosis to still provide service to
patients because of the greater negative
consequences of that action. The right
choice in this situation, unlike the one in
the superlative respect for autonomy, is
indeed no treatment.
Deciding what to do in a difficult
clinical situation depends on the key
players in the situation. If the dentist
abides by an interactive relationship,
then he or she would place the value of
autonomy above all other ethical considerations
(Ozar & Sokol, 2002). If the
patient is unable or unwilling to make a
decision, then the dentist can act on the
patient’s behalf and require a CBCT, or
even refuse treatment without it, because
such intervention can be justified on the
basis of preventing harm to someone
who is unaware of it, a practice otherwise
known as paternalism. Still, ethical
principles cannot provide solutions to
every clinical dilemma, since emotional
and real life factors may weigh heavier
than the ethical constructs. Patients
may have cultural or religious factors
that deter their ability to act on moral
considerations. Therefore, the discussion
of all pertinent ethical issues cannot
always lead to distinct right or wrong
decisions, but rather is limited to the
moral implications of making such
decisions (Hebert, 2009).
Unlike the consequentialist theory
that determines moral responsibility
on the sole basis of consequences, duty
theories view ethical behavior as an
extension of certain obligations irrespective
of the consequences that may follow.
According to the seventeenth century
German philosopher Pufendorf, the
scope of duties can be classified as
those to God, to oneself, and to others.
Concerning those duties towards others,
he claimed that absolute duties are those
that avoid wronging others and promoting
the good of others, no matter the
ends of such actions. Then, if applied to
the dilemma of routine CBCT scans in
dental practice, we can argue that any
dentist who is aware of the harmful
effects of radiation is wrong in giving all
patients a CBCT scan, even if such scans
produce good consequences in some
cases. In pure duty theory, one should
not harm a patient to justify any positive
outcomes of that harm.
Another framework for this discussion
comes from virtue theories popularized
by philosophers such as Aristotle, who
believed that developing good character
traits early on determines ethical actions
in the future. Rather than following
rules of ethics, an individual who learns
from moral education will act on moral
principles when confronted with an
ethical dilemma. A dentist, then, could
rely on virtues like justice and honesty in
the decision-making process regarding
the CBCT scan, which may lead to
different conclusions about the need for
CBCT scans in the face of adequate and
safer technology. For example, rather
than setting rules for which patients
and which cases necessitate additional
scanning, the dentist can act benevolently
in every situation to promote the virtue
of honesty. This means that truth-telling
takes precedence over the need to
produce better treatment outcomes.
Similar to this principle is the belief of
the eighteenth-century philosopher
Immanuel Kant that lying is always
wrong no matter the benefit it produces
(Hebert, 2009). In modern clinical practice,
this has not always been an easy
task, especially when truth-telling to
patients is rarely black and white. When
diagnosis, prognosis, and potential
effects of treatments are uncertain,
clinicians may opt for the therapeutic
“white lie” in order to fulfill wishes of
patients such as maintaining hope. In
this specific case, however, truth-telling
applies to the full disclosure of risk
rather than the omission of irreversible
harm. Patients do have the power to
change the fate of such accumulated
risks, and thus, should be provided the
means to do so. It is a weak argument
20 years from now to say that a correctly
aligned implant (positive outcome) was
worth a consequent cancer of some
form (negative outcome). Kant’s proponents
therefore dismiss consequences
of behavior altogether and instead
place emphasis on acting according to
universal law.
Whether an emphasis on duty or
consequences gives the best account of
morality remains to be established, but
2011 Volume 78, Number 4