246 Volume 5 • Issue 4 October / December 2015 •

Synthesis

ETHICAL CHALLENGES IN AESTHETIC DENTISTRY

Marius NEAGU1, Bianca HANGANU2, Magdalena IORGA3, Beatrice IOAN4

1M.D., Ph.D. student, resident physician in Legal Medicine, “Gr. T. Popa” University of Medicine and Pharmacy Iasi, Romania2M.D., resident physician in Legal Medicine, “Gr. T. Popa” University of Medicine and Pharmacy Iasi, Romania3Ph.D., Lecturer, psychologist, “Gr. T. Popa” University of Medicine and Pharmacy Iasi, Romania4M.D., Ph.D., Associate Professor, “Gr. T. Popa” University of Medicine and Pharmacy Iasi, RomaniaCorresponding author: magdaiorga@yahoo.com.

AbstractAesthetic dentistry is a branch of dentistry which aims

primarily at improving patient’s physical appearance and, to a lesser extent, the functionality of teeth. This field raises particular ethical dilemmas and requires a careful evaluation of patient’s needs and wishes versus his/her clinical best interests. In this article, the authors discuss the main ethical challenges in the field of aesthetic dentistry in the light of the four “classical” principles of bioethics: autonomy, beneficence, non-maleficence and justice. The authors conclude that the principles of medical ethics should be at the very foundation of the field of aesthetic dentistry, for establishing a patient-physician relationship which could lead to optimum clinical outcomes, while respecting the wishes of the patient and promoting his/her best interests.

Keywords: ethics, bioethic principles, aesthetics, dentistry.

1. INTRODUCTION

Ethical principles are moral rules to be applied for achieving an ethically correct medical practice. The four “classical” principles - individual autonomy, beneficence, non-maleficence and justice - are the ideals to be aspired by all health care professionals, grounded in the core values of the medical profession [1].

Ethical standards in modern society need to be adapted to the rapidly changing situations of everyday life, in general, and of medical practice, in particular. In the last decade, a body of literature on ethics in dentistry has emerged. However, this field is still behind the level of the ethical debate in general medicine, despite the challenges raised by its rapid development [2,3].

Aesthetic dentistry involves the application of restorative techniques with the aim of improving patient’s physical appearance, without targeting functionality [4].

Patients might ask for aesthetic dentistry procedures for various reasons. Some wish to correct their dental aesthetic anomalies for granting longevity to their teeth. Others ask for dental improvement because of their narcissism, psychological or personality disorders, or career and social progression. Some of the aesthetic surgery procedures might improve the health and function of teeth, while others are of no benefit or even have a negative effect upon teeth [5].

Aesthetic dentistry raises complex and difficult questions related to the reasons for offering a particular treatment option to a particular patient, the proficiency of the physician in carrying out a certain procedure, the risk-benefit assessment and the correct information of the patient.

Analyzed in the present study are some of the ethical dilemmas which emerge in the field of aesthetic dentistry from the perspective of the above-mentioned ethical principles.

2. AUTONOMY

In general terms, autonomy is the capacity of a person for self-governance. In medical practice, the respect for autonomy allows the patients to make free and informed decisions on their medical care based on their own values and wishes. Respect for autonomy means, on one hand, providing relevant information to patients and, on the other, abstaining from inferring their choices. The dentist has the duty to inform the patient on his/her treatment options, including the risks and benefits of each of them, leaving the

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ETHICAL CHALLENGES IN AESTHETIC DENTISTRY

patient to make the final decision on the treatment preferred and also on the physician who will provide it [6].

In dental medicine and in aesthetic dentistry, informing the patient may become a difficult task, if considering the wide range of materials and techniques that may be used. At the same time, the physician needs to clearly differentiate between the needs and interests of the patient, and make this difference clear to the patient, as well [7]. The wish of the dentist to gain more money by recommending a certain expensive procedure, despite the best interest of the patient, and by providing to the latter partial information on it, in order to grant acceptance, is ethically questionable. This medical attitude generates a conflict of interests due to the double role of the dentist, as a health care provider and a professional - who runs his/her own private practice which, on long term, may have a “boomerang” effect, by affecting the professional reputation of the physician [8].

In the field of aesthetic dentistry, the psychological suffering of the patient is essential in the decision-making process. However, patient’s wishes are not absolute even if, as showed above, autonomy is a principle of utmost importance in medical practice [9]. The dental treatments need to strike the right balance between the aesthetic aspect of teeth and their functioning. The dentist has the legal right and the deontological obligation to refuse to provide a certain procedure if he/she considers that it will not benefit or even harm the patient and might further compromise the former’s professional reputation [10].

3. BENEFICENCE AND NON-MALEFICENCE

Beneficence is reflected in the duty of every health care professional to maximize the good for his/her patient [11].

Non-maleficence derives from the ancient requirement Primum non nocere and, in contemporary practice, obliges physicians to avoid doing harm to patients and to protect them against harm [11].

The principles of beneficence and non-maleficence reflect each other and together impose to all physicians and, implicitly, to dentists, the duty to carefully balance the risks and benefits of the medical procedures offered to their patients for maximizing the former and minimizing the latter ones [11]. To do so, dentists have the duty to permanently update their theoretical and practical skills and also to treat the patients within the limits of their professional competence by respecting the current professional standards. They also have to keep in mind and accept that there are situations in which safeguarding patient’s welfare means to send him/her to health care professionals with superior knowledge, skills or experience [12].

In aesthetic dentistry, respect for beneficence and non-maleficence imposes to minimize the risks and maximize the benefits associated with the medical procedures by choosing the minimally invasive procedures, which are associated with lower risks and better results. A relevant aspect in this context is the impact of the aesthetic dentistry procedures on the general health status of the patient. This means, on one hand, that the dentist has to collect all relevant information about patient’s health condition and, on the other, that he/she has to adapt the procedures he applies for minimizing the risks to patient’s health [13]. In cases in which the risks of the aesthetic procedures for the health of the patient are significant and unjustified by the expected results, the principle of autonomy will be overshadowed by the duty of the dentist to promote the benefit and to minimize the risks to the patient [14].

4. JUSTICE

Equitable access to health care is a basic human right, as stated in the UN Universal Declaration of Human Rights: “everyone has the right to a standard of living adequate for health and well-being, including medical care and necessary social services” [15]. Theoretically, according to the principle of justice, physicians have the duty to make sure that medical care is available to all people [1,16]. Practically, the medical resources are limited, especially for

248 Volume 5 • Issue 4 October / December 2015 •

Marius NEAGU, Bianca HANGANU, Magdalena IORGA, Beatrice IOAN

expensive medical procedures - such as aesthetic dentistry. As a consequence, not all persons who would like to benefit from aesthetic dentistry will actually have this possibility [17]. Rationing takes place on the basis of the clinical need, which in itself becomes subjective when it comes to judgements on the “level of need”. In the private sector - which is the case of most practicing dentists - patient’s capacity of payment also becomes a relevant selection criterion [18].

Nevertheless, one should not forget that dentists have the general duty to provide care to those in need. It becomes unethical for the dentist to refuse medical care to certain patients on discriminatory grounds, such as a particular pathological condition (e.g., HIV positive status, hepatitis), race, sex, political orientation, religious beliefs, etc.

5. CONCLUSIONS

Aesthetic dentistry is an emerging field in which new and specific ethical dilemmas raise and add to the “classical” ones of dental medicine. Given the particular aims of aesthetic dentistry, health professionals have the duty to find the proper balance between the treatment with functional purpose and the one with merely aesthetic results. The principles of medical ethics should be at the very foundation of this field, for creating a functional patient-physician relationship that could generate best clinical results while respecting the wishes of the patient and promoting his/her best interests.

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