Respect for autonomy is one of the four basic principles in medical ethics that has been widely accepted over the last twenty years. Autonomy gives rise to our duty to permit individuals to make informed decisions about factors affecting their health. It is this issue as it pertains to informed consent that is at the heart of many ethical dilemmas that occur in dentistry. As an example, a patient who values the preservation of her teeth may be deprived of that opportunity if her dentist assumes that she will want an abscessed tooth removed because he believes she cannot afford the root canal treatment. A conflict with the dentist may arise in attempting to respect the patient's autonomy if the patient requests the extraction of her remaining ten maxillary teeth and the delivery of a denture in lieu of possible periodontal therapy and a removable partial prosthesis. In this situation, the dentist has to decide whether to do what the patient wishes or what seems to benefit her most.
What seems to have complicated matters even more as related to this ethical principle of autonomy is the manipulative invasion of the doctor-patient relationship from the third party. Since following principles of medical/dental ethics is not a responsibility of the insurance industry, there may be an immediate conflict created between the dentist and patient when the third party becomes involved. What has made matters worse is that we, in our profession have at least to some extent "bought" into this fiasco every time we communicate to the patient that the insurance may or may not cover a particular procedure. By having insurance companies dictate what procedures are or are not covered (and to what dental office the patient must go to have their dental treatment) we may violate the patient's autonomy. If we treat our patients based on what their insurance allows, we are as guilty as the insurance industry in violating their autonomy if we don't take time to explain the patient's treatment options regardless of their insurance coverage. By abiding by the insurance company's guidelines as to what treatment is covered, we often may neglect to inform the patients of the possible treatment options that are available to them in restoring their dental health. Let us not assume for example, that the patient may not want an inlay/onlay restoration that their insurance may not cover in lieu of that large amalgam that their insurance will pay for. On the other hand, let us not crown the tooth that may be treated more conservatively just because the insurance company will pay for it, especially if there is other higher priority treatment necessary. Is there a solution?
Enter direct reimbursement. Thankfully, our profession has a golden opportunity to turn the tide and restore the patient's autonomy, their right to choose the most beneficial dental treatment unencumbered by the insurance industry. The Orange County Dental Society is fortunate to have been chosen by the CDEEA to test Direct Reimbursement as a viable solution to the insidious invasion of the insurance industry by cutting out the middleman. We all know that this two-edged sword we call dental insurance has become increasingly one sided to the obvious benefit of the third party.
Let us be masters of our own destiny by placing more effort into affecting positive change and less effort in complaining by embracing this opportunity to make Direct Reimbursement a resounding success. It can only be successful if we make a collective effort as a component. I believe this is what we call "organized dentistry." As usual, the ethics committee looks forward to printing reactions, responses, comments, editorials, etc.
Reprinted from the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report; Ethical Principles and Guidelines for the Protection of Human Subjects Research. Washington DC: US Government Printing Office; 1978
Beauchamp, TL. Childress, JF. Principles of Biomedical Ethics, 3rd ed. New York NY: Oxford University Press: 1989
Veatch, RM. A Theory of Medical Ethics, New York NY: Basic Books: 1981
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