Deciding when and how to apply the best interest principle to the care of a patient isn't always straightforward.
The GDC's Standards for the Dental Team first principle requires all registered dental professionals to put patients' interests first, but doing so can pose some difficult ethical dilemmas.
Standard 1.7.1 states 'you must always put patients' interests before any financial, personal or other gain'. Standard 8.1 includes that you must raise a concern if you think patients are at risk because of a colleague, the environment where treatment is provided, or if you're asked to do something that conflicts with your responsibilities to patients' interests and safety. This obligation comes before any concerns you might have about your position or influence, as well as any professional or personal loyalties.
These principles apply to the wider aspects of the care of patients, not just to the clinical treatment itself, and involve patient safety both within and outside the surgery. For example, if you had a concern that a child or a vulnerable adult was being abused at home or in an institution, you would have an ethical duty to act by raising your concern and ensuring it was properly addressed. The GDC requires you to be familiar with local procedures for the protection of children and vulnerable adults.
However, care needs to be taken not to act in a paternalistic fashion and fail to take into account the patient's wishes. If, for instance, you suspected that a mentally competent adult patient was being physically abused by their partner, it would be reasonable to raise your concern and discuss it with them in private, perhaps suggesting where they might get help.
But it could well be inappropriate to raise your concern with, say, the police. The patient may be choosing to remain in an abusive relationship for reasons which you find difficult or impossible to understand. Nevertheless this is a decision for the patient alone, because they are an adult with the capacity to make their own decisions.
In relation to the clinical treatment itself, the GDC's Standards say that treatment given to patients must be in their best interests, providing them with appropriate dental health advice and following any clinical guidelines that are relevant to their individual circumstances. There's also often a need to weigh up their health needs with what they want to get from the treatment, and if this isn't achievable or is not in the best interests of their oral health, you need to help them reach a decision by explaining the various risks, benefits and outcomes.
It goes on to say that:
- the care you provide must be based on current evidence and guidance
- you must take responsibility for finding and following this guidance and evidence
- if you deviate from the current establish practice or guidance, you should record why and be able to justify your decision.
Again, save in circumstances where patient consent cannot be obtained, a paternalistic approach is not appropriate. Patients with the capacity to consent have a right to decide what happens to their bodies and what treatment they wish to undergo. Even if a patient's wishes appear illogical and contrary to their best interest, provided the patient has the capacity to give valid consent, their wishes should be respected.
At the same time, no dental professional should be forced to provide treatment which is against their considered professional opinion and which they consider is not in the patient's best interest. Treatment should always be in line with current accepted practice and teaching as would be supported by a responsible body of opinion, and failure to provide treatment which meets these standards would amount to negligence. This would then entitle the patient to financial compensation if they suffered avoidable harm as a result.
No dental professional should be forced to provide treatment which is against their considered professional opinion and which they consider is not in the patient's best interest.
Only appropriately qualified and experienced dental professionals have the training to formulate a dental treatment plan. This plan should of course take into account the patient's requests and desired outcomes, and they have the right to accept or reject it.
If the treatment requested by the patient is considered not to be in line with current accepted practice and teaching, and not in the patient's best interest, it simply should not be provided, and the dental professional should explain the reasons for their decision. In such a situation, sometimes offering the patient an independent second opinion can be helpful.
Concerning consent, as a result of the Montgomery judgement patients with capacity have a right to know all the available options for treatment, and the material risks of each option to which a reasonable patient would attach importance.
If the patient lacks capacity for whatever reason, then the provisions of the Mental Capacity Act 2005 apply. The underpinning principles are:
- a person must be assumed to have capacity unless it is established they lack it
- a person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success
- a person is not to be treated as unable to make a decision merely because they make an unwise one
- an act done or decision made under the Act for or on behalf of a person lacking capacity must be done in their best interests
- the least restrictive option - anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms.
The DDU's team of highly experienced dento-legal advisers frequently offer advice to members on difficult ethical issues. In the case of best interest dilemmas, there is often not one single right answer and they are ultimately a matter of careful professional judgement.
Provided you can demonstrate that you were aware of the relevant GDC standards and law, you applied them in good faith, you sought advice as necessary (including DDU advice), and you truly considered a particular course of action to be in the patient's best interest, you are unlikely to be justifiably criticised.
Senior dento-legal adviser
Rupert Hoppenbrouwers (BDS LDSRCS) was head of the DDU until his retirement at the end of 2015. He is a former general dental practitioner and was director of the School of Dental Hygiene at University College Hospital, London, from 1980 to 1986. He has lectured and written widely on risk management and dento-legal matters, has previously chaired the UK Dental Law and Ethics Forum, and has a particular interest in complex ethical and legal issues affecting dental members.
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