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32241 Crown Valley Parkway #200
Dana Point, CA 92629 | Directions

ETHICS COMMITTEE REPORT

- Ethics question number 7

Should I treat the HIV positive patient?
Although it seems that AIDS in dentistry has faded somewhat from the public's focus, within the last year there have been some precedent setting cases that should realign our thoughts with this serious issue. The statistics from the Department of Justice (DOJ) make it all too clear that the confusion in our profession is pervasive. In their report to the ADA, the DOJ cited that 25 percent of the current HIV/AIDS discrimination investigations are of claims against dental providers in the context of places of public accommodations. This translates into approximately 40 percent HIV/AIDS discrimination investigations of all health care providers.

Based on DOJ's ruling, the issue becomes very clear; as health care providers, we are obligated to treat HIV/AIDS patients lest there be a breach in the Americans with Disabilities Act. However, it is not so clear as to why there is such confusion in this matter relative to our ethical position, thus, the aforementioned statistics may not come so much as a surprise. Perhaps some discussion may offer clarification.

Since the inception of our profession, becoming a dentist rarely posed the possibility that providing care to patients might place one's life at risk of a fatal infection. In 1980, this frame of mind changed forever with the advent of the HIV virus and the subsequent syndrome we are all too familiar with. Not only was the dental profession faced with the reality of treating individuals with a terribly fatal infection, but treating the powerful social stigma that accompanies this disease added a new dimension to the problem. This intrusion happened so abruptly that a store of well-thought-out answers is not available to our profession as this involves much philosophical thought. The challenging discussion continues with the hope of raising our comfort level with this intense issue. The importance of this philosophical process is perpetuated due to the fact that medical science's efforts in finding a definitive answer to the AIDS riddle has been foiled time and time again, with no solutions in sight.

Looking back in history may shed some light in what might be considered appropriate or inappropriate behavior. It was in biblical times that quarantine colonies were established in sequestering whole segments of society from the terrible affliction of leprosy. We now understand how difficult it was to contract leprosy from this mycobacterium infection. However, the social stigma associated with the disfigurement provided the ill-founded basis of such colonies. Granted, modern medicine was not available as an information source then, in making socially responsible decisions. However, today we do not have the same excuse. Clearly, the respected think tanks for dentistry (CDC, ADA etc.) have provided a rational basis for our profession to follow in dictating our treatment modes and behavior towards the HIV/AIDS patient. The alternative would be to follow our irrational emotion of ignorance. I think we can consider ourselves as a highly educated bunch which automatically should make ignorance a mutually exclusive response., however as we all know, education is a continuing process ergo, CE.

The ADA's policy, passed by its House of Delegates in 1988, two years before the Americans with Disabilities Act was passed by Congress, states that a dentist should not refuse to treat a patient whose condition is within the dentist's realm of competence solely because the patient has HIV. The policy also states that "HIV-infected individuals can be treated safely in private dental offices when appropriate universal precautions are used." We must also understand that our obligation to the public in our risk taking does have limits. If the risks were great enough, even with our universal precautions in caring for the infectious patient, then there would be good reason for the community at large to indeed limit our obligation to such patients due to an unjustifiable risk. This would be so because our ability to provide dental services to the whole community would be seriously threatened assuming a high casualty rate of our colleagues. Therefore, it becomes an issue of the needs of community as a whole outweighing the needs of the individual. The nature of AIDS/HIV with the use of the universal precautions however, make the aforementioned scenario irrelevant at this point in time. Because of the identifiable risks to the dentist's life along with his/her capability to control those risks through caution minimizes the contraction of the HIV condition; our professional obligation to the HIV/AIDS patient becomes less vague. If we choose as individuals to ignore or challenge the wisdom of the ADA in giving way to our emotion and fear, then perhaps reflecting on the CDC statistics relating to dentists contracting the AIDS virus should provide consolation. If this still provides minimal comfort then it would be consistent that such an individual does not drive on city streets, fly the airlines, or swim in the ocean for fear of shark attacks, all behaviors associated with a much higher risk incidence. For those individuals I offer my heartfelt consolation. For the rest of us, both the community at large expects, and other members of the health professions are committed to, accepting a greater than ordinary risk to our lives if this is necessary for the proper care of our patients. This is one of the reasons why we are held in such high esteem and respected by our community, and thus, must maintain such trust. Because we are highly educated and trained, however, the risk becomes minimal.

We must also understand that our obligation to the public in our risk taking does have limits. If the risks were great enough, even with our universal precautions in caring for the infectious patient, then there would be good reason for the community at large to indeed limit our obligation to such patients due to an unjustifiable risk. This would be so because our ability to provide dental services to the whole community would be seriously threatened assuming a high casualty rate of our colleagues. Therefore, it becomes an issue of the needs of community as a whole outweighing the needs of the individual. The nature of AIDS/HIV with the use of the universal precautions however, make the aforementioned scenario irrelevant at this point in time.

The Ethics Committee requests any feedback or editorial comments from our dental component in remaining sensitive to your needs.

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