Developing Ethical Codes to Enhance Dental Practice Standards

The mission of dentistry is to provide high-quality services to preserve and promote the oral and dental health of the population [1]. These preventive and therapeutic services should be delivered at the highest standard. To achieve these great goals, a dentist enters this field as a professional.

The principles of professional ethics comprise the commitments that people in a profession have towards society [1]. The society expects a professional person to give priority to the patients’ and society’s health over personal benefits in all professional decisions, which is the most important way of enhancing the public trust [1]. To present dental services with maximum efficacy, it is necessary that service providers commit themselves to advocate ethical considerations, which would result in the peace of mind and security of patients and society.

Medical ethics is a structured system aiming at providing proper strategies to solve ethical challenges in the field of medicine [2]. Ethical goals and values, formulated as ethical codes, can be utilized as a source for ethical decision-making and performance of dentists. The aim of developing professional ethical codes for dentists is to provide an ethical standard for dentists’ practice, to inform the public of these standards, and to achieve professional integrity [3].

The Universal Declaration of Human Rights (UDHR) emphasizes respect for patient dignity in healthcare [4]. Analysis of professional ethical responsibilities reveals a series of common irrefutable ethical principles; for example, there are no doubts about the necessity of respect, confidentiality, and fidelity. Although ethical considerations guarantee that these general principles are observed, they should be defined exclusively for each profession.

In professions where human relationships, whether in the form of a relationship with a patient or a colleague, are stronger, the exact specification of these principles seems more necessary. An example of such professions is dentistry. Observation of patients’ rights is one of the most important professional principles in medical ethics. The dental associations have codified the written expression of the obligations arising from the implied contract between the dental profession and society.

The most prestigious code is developed by the American Dental Association (ADA) under the title “Principles of Ethics and Code of Professional Conduct”, which is updated annually [5]. The practice involves all dentists who are members of this association. The latest version of the ADA ethical codes (2018) has three main components: “the Principles of Ethics, the Code of Professional Conduct, and the Advisory Opinions” [5].

One of the most comprehensive ethical guidelines has been developed by the General Dental Council (GDC) of England in 2013 [6]. This document regulates the standards of conduct, performance, and ethical principles and guidelines that govern dental professionals. It also specifies what patients can expect from dental professionals [6].

The American College of Dentists (ACD) has dedicated the Ethics Handbook for Dentists to the dental profession since 2000 and reviews it every four years; this handbook serves as a useful introduction to ethics, professionalism, and ethical decision-making. It involves ethical issues related to advertising, child abuse, competence and judgment, confidentiality, the delegation of duties, social media, disclosure and misrepresentation, financial arrangements, informed consent, refusal, obligation, and refraining from treating patients [7].

The Australian Dental Association also has ethical principles for professional behavior and four principles of medical ethics. It also specifies the ethical obligations of dentists towards patients, staff, colleagues, and associations [8,9]. A great deal of attention has been recently paid to the development of the principles of medical ethics in Iran, resulting in the development of general and specific codes of research ethics, comprehensive documentation of the country's drug system, nursing code of ethics in Iran, professional ethics charter of psychiatry in Iran, and patients’ rights charter [10-13].

In 2018, the Medical Council of the Islamic Republic of Iran published general ethical guidelines for healthcare professionals and affiliates under 11 titles, including general obligations, high-quality service delivery, priority of patient benefits, justice and impartiality, honor and integrity, respect for autonomy, confidentiality and privacy, management of medical errors, relationship with colleagues, organizational and social responsibilities, dress codes in the clinical environment, medical education, and research. The Iranian medical community is required to observe the codes presented in the guidelines; failure to comply can result in prosecution and penalty [14].

These priorities are also shared in dentistry as a branch of medical sciences; however, due to the differences in the activities of dentists and their relationship with patients compared to medicine, it is imperative to develop specific ethical considerations for dentistry. Dentists have to make different decisions as a result of technological advances in prevention, diagnosis, and treatment as well as changes in the economic status and expectations of patients. The public release of ethical considerations will serve as a guide for service providers on how to deliver the service. Moreover, due to cultural, social, economic, and religious differences of Iran with other countries, certain issues in the dentist-patient relationship, such as a close, prolonged physical contact with the patient and a greater proportion of out-of-pocket payment, are different from those in other countries. Since the establishment of a dental school with the management of Melczarski in 1930 [15], no attempt has been made to develop codes of ethics for dentists despite their necessity. Moreover, although professional dentists are committed to adhering to generally accepted ethical codes, few studies have evaluated whether dentists exercise these principles in practice. The aim of this study was to develop ethical codes for Iranian general dentists to serve as a preliminary source for providing a tool for assessment of the current ethical status of dentists, to achieve standardized codes, and to improve the dentists’ professional performance.

MATERIALS AND METHODS:

The present study was conducted at the Dentistry Research Institute of Tehran University of Medical Sciences, Tehran, Iran, from August 2016 to July 2018. This qualitative study was performed in three phases:

Phase one: A comprehensive and systematic search was conducted using published books, manuscripts, and articles as well as internet databases to retrieve some guidelines and papers most relevant to “code of conduct” and “code of ethics” in combination with the terms “dentist”, “dentistry”, and “dental”.

Thirty ethical codes for dental foundations around the world and 56 papers on dental ethics were gathered. Their items were analyzed through a directed content analysis method according to the method proposed by Zhang and Wildemuth involving eight steps [16], and finally, 196 items were extracted from the ethical codes and the articles. The items retrieved in this stage were used to develop the questionnaire used for interviews.

Phase two: Purposive sampling with maximum variation was applied to select the participants from among faculty members with different dentistry specialties. At the beginning of the interview, each participant was informed about the aim of the study and was ensured of confidentiality. Informed consent was gained from the participants. The questionnaire was used to conduct semi-structured interviews with dentistry specialists to determine their point of views about ethical considerations and priories in dentistry and to identify the most important challenges and problems.

The interviews were continued until data saturation. Fifteen interviews were audio-taped, and the audio file of each interview was saved using the participant’s unique code, was immediately transcribed verbatim, and was analyzed according to predetermined items. The statements made by the specialists served as a basis for the assembly of items. Overall, 105 items were obtained through the interviews, which were combined with the terms gathered during phase one. At the end of this phase, a preliminary draft of the codes of ethics, consisting of 196 items, was set up. The categories were deduced from the items using a continuous comparison method, and the items were placed in 12 proper subcategories according to their properties and similarities. The researchers continuously reviewed earlier stages of the research in detail.

The content analysis approach was directed in this study, in which the results of previous studies and predefined classifications were used as an analysis-based guide, and thus, the frameworks of existing theories were validated and developed [17].

The aim of the directed content analysis was to accredit and develop the theory used in the research so that the previous theories help specify the key concepts or variables.

Phase three: In two focus group discussions with the participation of six experts who had adequate information and experience in this field, the preliminary draft of the codes of ethics was discussed and analyzed. Some items were deleted, some new items were added, and some items were combined. Eventually, 90 items were classified into five categories, as an initial schema, based on the perspectives and experiences of the experts in the sociocultural and religious context of Iran. The reliability of the research was established according to Lincoln and Guba's evaluative criteria, including credibility, dependability, conformability, and transferability [18]. Continuous observation, long-term involvement with research issues, good communication and interaction with the participants, and using triangulation for data gathering were beneficial for promoting the validity of the research. Finally, the first edition of the codes of ethics was prepared, which comprised 90 items in five categories. In two focus group discussions with a group of three experts in the field of writing ethical codes, the codes were extracted and finalized as the final edition of the ethical codes. A questionnaire with 5-point Likert scale was set up, and 20 dentists with more than 15 years of experience were invited to comment on the importance and clarity of the items to establish face validity of the codes; the necessary changes were made accordingly. The ethics of the study have been approved by the Vice-Chancellor in Research Affairs - Tehran University of Medical Sciences (IR.TUMS.VCR.REC.1395.732). The objectives of the study were explained to the participants and their agreement was obtained. The recorded information was anonymous and securely stored.

Conclusion

In conclusion, this text highlights the pivotal mission of dentistry, emphasizing the delivery of high-quality services to preserve and enhance oral and dental health. It underscores the importance of professional ethics in dentistry, aligning with societal expectations and prioritizing patient well-being over personal benefits. The text explores the role of medical ethics, ethical codes, and international guidelines in shaping the conduct of dentists.