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 (SHCN) are entitled to oral health care that meets the treatment and ethical standards set by our specialty.

Methods

This policy was developed by the Council on Clinical Affairs and adopted in 2003.1 This document is a revision of the previous version, revised in 2015.2

Background

Dentists have an obligation to act in an ethical manner in the care of patients with consideration of the virtues of ethics including autonomy, beneficence, nonmaleficence, and justice. Autonomy reflects the patient’s or, when the patient is a minor or an intellectually disabled adult who lacks capacity to give consent, the parent’s3 or guardian’s right to be involved in treatment decisions. The caregiver 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 there may be conflicts with the dentist’s personal self interests. Nonmaleficence dictates that the dentist’s care does not result in harm to the patient. In situations where a dentist is not able to meet the patient’s needs, referral to a practitioner capable of providing the needed care is indicated. Justice expresses that the dentist should deal fairly with patients, colleagues, and the public.4,5

Denial of care by the provider because of 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 a dentist is unable to provide medicallynecessary care6, he has an ethical responsibility to refer the patient to a practitioner or facility capable of providing the care.

Oral health care practitioners may offer services for children and individuals with SHCN in a variety of settings (e.g., solo practice, general dentistry group practice, specialty group practice, dental service organization, educational institution, hospital, public health or military clinic). Although each entity will have its own administrative policies and procedures to which practitioners must adhere, each provider also must be aware of and follow established standards and evidencebased guidelines promulgated by organizations with recognized professional expertise and stature.

Dentists are held responsible for their clinical and ethical decisions regardless of who holds the responsibility for business decisions.7 The “ultimate responsibility for compliance with state laws and regulations falls upon the practicing licensed dentist.”8 All patients must receive dental care consistent with the moral, ethical, and evidence-based standards of care regardless of the care setting. The treating doctor’s clinical judgment should not be influenced by financial considerations of the business entity.

Patients/parents need to play an active role in decision making with their doctors and must be informed about their medical and dental problems and treatment options.4 Evidence-based knowledge and treatment options are evolving at a rapid pace. As a result, patients/parents and health care providers are seeking second opinions so that more informed decisions based on the risks and benefits can be made for treatment. A provider has an ethical obligation, subject to privacy regulations, on request of either the patient or the patient’s new provider to furnish records, including radiographs, or copies of them. These may be beneficial for the future treatment of that patient.4 Health Insurance Portability and Accountability Act (HIPAA) privacy rules9 and state laws apply to all exchanges of health care information. Educating the patient/parent regarding the diagnosis and available treatment options, including their risks and benefits, should be the goal of a second opinion consultation. Health care providers may disagree on the best treatment for an individual patient. Any opinion should be rendered only after careful consideration of all the facts and with due attention given to current and previous health status of the patient. When presented with requests for second opinions, practitioners should consider the legal implications of such requests. Health care providers rendering second opinions unwarily could be involved in litigation, either on behalf of the patient or in defending themselves against other practitioners as a result of the consult. The fact that one is the second or third consulted professional does not mean that the provider is exempt from liability.10 Parents and patients should be fully advised of their health status without disparaging comments about their prior treatment or previous provider.

Policy statement

Infants and children through adolescence, including those with special health care needs, have a right to dental care. The AAPD believes it is unethical for a dentist to ignore a disease or condition because of the patient’s age, behavior, or disabilities. Dentists have an ethical obligation to provide therapy for patients with oral disease or refer for treatment patients whose needs are beyond the skills of the practitioner.

The AAPD encourages all entities and practitioners who provide oral health care services to children to follow evidencebased clinical practice guidelines and best practices developed by organizations with recognized professional expertise and stature. Under no circumstance should the business or corporate entity interfere with the clinical judgment of the treating dentist.

A patient/parent has a right to a second opinion. A provider who is trained and experienced in diagnosing and treating the condition is encouraged to provide the second opinion. When presented with requests for second opinions, practitioners must consider the legal implications of such requests. Patients/parents should be fully advised of their health status without disparaging comments about their prior treatment or previous provider.

The AAPD advocates legislation or regulation at the federal and state levels to ensure that dentists are free to exercise individual professional clinical judgment and render appropriate treatment to their patients without undue influence or infringement by any third-party business and entity.11,12

References

  1. American Academy of Pediatric Dentistry. Policy on the ethics of failure to treat or refer. Pediatr Dent 2003;25(Suppl):49.
  2. American Academy of Pediatric Dentistry. Policy on the ethical responsibilities in the oral health care management of infants, children, adolescents, and individuals with special health care needs. Pediatr Dent 2015;37(special issue):114-5.
  3. American Academy of Pediatric Dentistry. Overview: Definition of parent. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:8.
  4. American Dental Association. Principles of Ethics and Code of Professional Conduct. With official advisory opinions revised to November 2018. Available at: “https://www.ada.org/~/media/ADA/Member%20Center/Ethics/Code_Of_Ethics_Book_With_Advisory_Opinions_Revised_to_November_2018.pdf?la=en”. Accessed September 14, 2020.
  5. American College of Dentists. Ethics Handbook for Dentists. Introduction to Ethics, Professionalism, and Ethical Decision Making. Gaithersburg, Md.: American College of Dentists; 2016. Available at: “https://www.acd.org/publications-2/ethics-handbook/”. Accessed September 14, 2020.
  6. American Academy of Pediatric Dentistry. Definition of medically-necessary care. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:18.
  7. Academy of General Dentistry Practice Models Task Force. Investigative Report on the Corporate Practice of Dentistry, 2013. Chicago, Ill.: Academy of General Dentistry. Available at: “https://www.agd.org/docs/default-source/advocacy-papers/agd-white-paper-investigate-report-on-corporate-dentistry.pdf?sfvrsn=c0d75b1_2”. Accessed September 14, 2020.
  8. Association of Dental Support Organizations, Dentists for Oral Health Innovation, Waller. Toward a common goal: The role of dental support organizations in an evolving profession. July 1, 2014. Dentists for Oral Health Innovation, Waller, contributors. Available at: “https://www.dentalonejobs.com/wp-content/uploads/2017/02/ADSO-White-Paper.pdf ”. Accessed July 21, 2020.
  9. U.S. Department of Health and Human Services. Health Information Privacy: The HIPAA privacy rule. Available at: “https://www.hhs.gov/hipaa/for-professionals/privacy/index.html#:~:text=The%20HIPAA%20Privacy%20Rule%20establishes,certain%20health%20care%20transactions%20electronically”. Accessed July 21, 2020.
  10. Machen DE. Legal aspects of orthodontic practice: Risk management concepts. Am J Orthod Dentofacial Orthop 1990;937(3):269-70.
  11. American Dental Association. Dentist’s freedom to exercise individual clinical judgment (Trans.1997:705). Current Policies 2018:177. Chicago, Ill.: American Dental Association; 2018. Available at: “https://www.ada.org/~/media/ADA/Member%20Center/Members/current_policies.pdf?la=en”. Accessed September 26, 2019 .
  12. American Dental Association. Statement Regarding Employment of a Dentist. (Trans.2013:353). Practice Administration. In: Current Policies Adopted 1954-2019. Chicago, Ill.: American Dental Association; 2019:168. Available at: “https://www.ada.org/~/media/ADA/Member%20Center/Members/current_policies.pdf?la=en”. Accessed September 26, 2019.