Policy on the Ethical Responsibilities in the Oral Health Care Management of Infants, Children, Adolescents, and Individuals with Special Health Care Needs
Purpose
The American Academy of Pediatric Dentistry (AAPD) believes that all infants, children, adolescents, and individuals with special health care needs are entitled to oral health care that is evidence based and meets the moral, legal, and ethical standards set by our specialty.
Methods
This policy was developed by the Council on Clinical Affairs, adopted in 2003, 1 and last revised in 2020. 2 This revision is based on a search of the PubMed®/MEDLINE database using the parameters: (evidence based dentistry [Majr] OR dentistry [Majr] OR dental care for children [Majr] OR pediatric dentistry [Majr]) AND (ethical respons* [Tiab] OR vulnerable populations [Majr] OR ethics [Majr] OR codes of ethics [MeSH] OR ethics, clinical [MeSH] OR ethics, dental [MeSH] OR pediatric bioethic* [Tiab]); filters applied: in the last 10 years, English. Five hundred-seventy articles matched these criteria. Papers for review were chosen from this list, references within selected articles, and updates of previously cited publications. Consensus opinion by experienced researchers and clinicians also was considered.
Background
Ethical care is distinct from the legal obligations required of an oral health care professional.3 The provision of ethical care for dental patients includes consideration of autonomy, beneficence, nonmaleficence, justice, and veracity. 4 Autonomy reflects the right of the patient or, when the patient is a minor or an intellectuallydisabled adult who lacks capacity to give consent, the parent (as defined in by AAPD)5 to be involved in treatment decisions. The patient/parent must be informed of the problem and that treatment is recommended. Beneficence indicates the dentist has the obligation to act for the benefit of the patient in a timely manner even when conflicts with the dentist’s personal self-interests may exist. Nonmaleficence dictates that the dentist’s care does not result in harm to the patient. Justice expresses that the dentist should deal fairly with patients, colleagues, and the public.4 Veracity is the principle of communicating with honesty, intellectual integrity, and truthfulness in order to maintain the trust inherent in the patient-provider relationship. 4
Denial of care by the provider because of the patient’s age, behavior, inability to cooperate, disability, or medical status can result in unnecessary pain, discomfort, increased treatment needs and costs, unfavorable treatment experiences, and diminished oral health outcomes. If the patient’s medicallynecessary oral health care needs exceed the dentist’s scope of practice, referral to a practitioner or facility capable of providing the care is indicated.
Oral health care professionals may offer services for infants, children, adolescents, and individuals with special health care needs in a variety of settings (eg, solo practice, general dentistry group practice, specialty group practice, dental service organization, educational institution, hospital, public health or military clinic). Not only are practitioners obligated to adhere to the administrative policies and procedures of their practice facilities, but they are subject to local, state, and federal regulations and evidence-based clinical practice guidelines directed toward upholding the highest standards of patient care and safety. No matter who is responsible for a facility’s administrative decisions, each oral health care professional bears accountability for his clinical and ethical decisions.6 The ability to exercise independent clinical judgment without influence from external business or financial interests is essential to ensuring the highest ethical standards. Staying current on regulatory aspects of different practice models helps oral health care professionals ensure they fulfill their obligations to patients and governing agencies. All patients have the right to receive dental care consistent with the moral, ethical, legal, and evidence-based standards of care regardless of the care setting.
Patients/parents are entitled to an active role in decision making with their doctors and to be informed about their medical and dental conditions and treatment options.4 Informed consent is an essential component of oral health care and involves active and ongoing communication and education between the dentist and the patient/parent. Older child and adolescent patients can be included in the decision-making process when provided developmentally-appropriate information about their oral health conditions and treatment options. Even though a child's assent may not be required legally, involving children in their care can foster their moral growth and development of autonomy. A child’s dissent may be given significant weight, especially when the proposed intervention is not essential or can be safely deferred.7 Because evidence for various treatment techniques and materials continues to expand at a rapid pace, patients/parents and health care professionals may seek second opinions in order to make informed decisions based on the risks and benefits of dental treatment options. A professional has an ethical and legal obligation, subject to privacy regulations, on request of either the patient or the patient’s new provider to furnish copies of treatment records, including radiographs. Health Insurance Portability and Accountability Act (HIPAA) privacy rules8 and state laws apply to all exchanges of health care information. When providing a second opinion consultation, educating the patient/parent on the diagnosis and available treatment options, including their risks and benefits, is foremost. Health care professionals may disagree on the best treatment for an individual patient. Careful consideration of all the facts, including a meticulous patient history, prior to rendering an opinion will foster professionalism and respect for one’s dental colleagues.
Policy statement
The American Academy of Pediatric Dentistry affirms the right of all infants and children through adolescence, including those with special health care needs, to receive oral health care consistent with moral, ethical, legal, and evidence-based standards of care. The AAPD maintains that neglecting a disease or condition based on the patient’s age, behavior, inability to cooperate, disability, or medical status is unethical. If a dentist cannot provide medically-necessary care, he has an ethical duty to refer the patient to a qualified practitioner or facility.
The AAPD emphasizes the ethical obligation of dentists to secure informed consent from patients/parents. Ethical care also includes obtaining assent prior to treatment from those pediatric patients who possess the cognitive maturity to engage in and understand treatment planning decisions.
The AAPD encourages oral health care professionals to adhere to established standards and evidence-based clinical practice recommendations developed by organizations with recognized professional expertise and stature. Furthermore, the AAPD supports the autonomy of dentists to use their professional clinical judgment, without undue influence or interference from third parties, in providing treatment to patients.
The AAPD encourages oral health care professionals who possess the necessary training and expertise to provide second opinions regarding diagnosis and treatment of the specific condition for which counsel is being pursued.