Abstract
Background
Respect for patient autonomy, the principle that patients are capable to make informed decisions about medical interventions, is fundamental in present-day medicine. However, if a patient’s request is medically not indicated, the practitioner faces an ethical dilemma represented by the conflict of the principles of patient autonomy, beneficence, and maleficence. Adjacent to topics such as medical assistance in dying and healthy limb amputation, this ethical dilemma also manifests in the care of the maxillofacial region (the oral cavity and its surroundings), an area crucial to esthetic appearance, but also to everyday functions including mastication, speech, and facial expression, all of which are related to well-being. Our aim was to explore the manifestations and resolutions of the conflict between oral health and patient autonomy in relevant literature in order to contribute to the discourse of ethical challenges concerning patient autonomy, beneficence, and nonmaleficence.
Methods
We screened all journal articles discussing the researched ethical dilemma obtained from three databases. Two researchers developed a hierarchical coding scheme, where the parent and grandparent codes were designated deductively as: Case (situations involving the researched ethical dilemma), Judgement (decisions made in the ethical dilemma), and Principle (ideas, rules, propositions explaining the judgements); child codes were developed inductively. After coding the sources, we utilized thematic analysis to construct code constellations.
Results
Most themes identified in our sources advocated for the practitioner to choose the alternative that benefits the patient from a medical perspective, although no theme excluded the consideration of patient autonomy. Instances where respect for patient autonomy was encouraged concerned oral preventive care or when the requested intervention was expected to have an insignificant impact on oral health.
Conclusions
Ethical conflicts concerning patient autonomy, beneficence, and nonmaleficence have a marked presence in oral care. These conflicts arise through the issue of body modification, evident in cosmetic dentistry and requests for tooth extraction. Our sources generally support the argumentation for beneficence, despite the rise of cosmetic procedures in dentistry.
Background
Respecting patient autonomy, the principle that patients are capable to make informed decisions about medical interventions, stands as a foundational principle for decision-making in contemporary medicine [1]; nonetheless, literature often describes complexities beyond its simple, idealistic, and universally accepted application. The problem’s intricacy originates in the interaction of patient autonomy with other ethical obligations, most notably with the principles of nonmaleficence, beneficence, and justice, as elaborated by Beauchamp and Childress [1]. Scholars have created ethical models combining features of patient autonomy and beneficence. Bester distinguishes between an objective, biomedical aspect and a subjective, individual aspect of beneficence affiliated with the patient’s goals and values [2]. Similarly, Cohen’s non-discrete model claims that patient autonomy and beneficence determine each other, therefore the patient’s own request is the most beneficial for them, albeit the request must be medically sound to be regarded as such [3]. Models that consider beneficence paramount include Rubin’s collaborative model, in which patients desire and require the practitioner’s expertise in a process of shared decision-making [4]. Further arguments in favor of paternalism in certain situations claim that personal values are constantly evolving, therefore requests may only represent short term desires (as opposed stemming from a stable sense of self) [5]. Likewise, the model by Chen and Das describing physicians as “ontological decision architects” also promotes mild paternalism in favor of beneficence [6].
Despite the theoretical attempts to integrate patient autonomy and other ethical obligations, conflict between them emerges if a significant segment of the medical community disagrees with the procedure demanded by the patient. Illustrative examples provided by Goodman and Houk include healthy limb amputation and providing medical assistance in dying, asserting that granting patient autonomy in these cases is an unacceptable violation of the ethical principles of nonmaleficence and beneficence [7]. In contrast, others do not condemn medical assistance in dying, but voice concern for current trends and policies [8, 9].On the other hand, healthy limb amputation in Goodman’s and Houk’s view is a form of body modification, and likened to other practices such as cosmetic surgery, circumcision, and sex reassignment-surgery [7, 10, 11]. Despite the analogy in these cases, as the alleviation of negative emotions via body modification among patients with body integrity identity disorder seeking limb amputation and those undergoing sex-reassignment surgery, healthy limb amputation is generally less accepted [10].
Ethical challenges encompassing general well-being, bodily integrity, and patient autonomy are also pivotal in oral care due to the established link between oral health and quality of life [12]. Moreover, connections have been established between oral esthetics and multiple dimensions of life, such as career advancement, increased popularity, richer intimate experiences, elevated self-assurance, improved social abilities, and enhanced academic achievements [13,14,15,16]. Social emphasis placed on esthetic value is also evident in the increased public interest in cosmetic dental procedures, leading to a surge in demand for these services [17]. Surveys indicate that 13-38% of the general population has opted for vital tooth bleaching [18], and dental professionals report performing this procedure on a monthly basis [19].
Literature investigating the ethical challenges of oral health and patient autonomy in dentistry is sparse. Ozar, Sokol, and Patthoff propose a theoretical value hierarchy for the dental profession, ranking health above all other values, including patient autonomy [20]. Rule and Veatch contend a significant limitation of this hierarchical framework is the absence of consensus regarding the suggested prioritization [21]. Research synthesizing various sources has been conducted by Witter et al., whose literature review of wish-fulfilling medicine compiled examples of ethically challenging situations involving patient autonomy in dentistry [22]. Despite this advantage, in the discussion of the dental cases, they only referred to legal considerations.
Our objective in this study was to explore relevant literature regarding the manifestations and resolutions of the ethical conflict between patient autonomy and oral health in dentistry providing a comprehensive analysis of this lesser-explored area in medical ethics. Our research question was: in what cases is the conflict between oral health and patient autonomy present in literature, what judgements are made in these cases, and which principles guide these judgements.
