Dental, Medical and Nursing Ethics:

Comparison 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

Outline of Presentation

• Sources

• Typical cases

• Similarities

• Differences

• Potential conflicts

• Resolving the conflicts

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

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.

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.

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 hospital’s 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.

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)

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.”

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 provider’s professional autonomy

with team approach to patient care• Recognition of institutional restraints on ethical

behaviour (political, administrative, commercial)

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.

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

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.”

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.

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

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)

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.”

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.

Joint Statement on Scopes of PracticePrinciples

• FocusScopes 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.

• FlexibilityA 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.

Joint Statement on Scopes of Practice

Principles

• Collaboration and cooperationIn 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.

Joint Statement on Scopes of Practice

Principles

• CoordinationA qualified health care provider should coordinate individual patient care.

• Patient choiceScopes of practice should take into account patients' choice of health care provider.

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.”

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.

Thank You!!!