Ethics and Dental Public Health Course Module

Ethics and Dental Public Health Course Module

Instructor Guide

The four- to six-hourcourse moduleis designed to build upon the student’s prior ethics understanding targeted to members of the health care provider team(Dentist and Dental Hygienist). Depending on the experience level of the students (first year versus senior students) the class may be shortened to four hours by removing some class discussions, or by assigning them to homework assignments.

The goal is to introduce the students to the type of ethical issues encountered by Dental Public Health (DPH) professionals and how the principles that guide the decision may vary from that of the dental practitioner treating individual patients, as well as the ultimate decision. A variety of cases are presented and suggestions for their use in each class session on how to stimulate discussion to engage in ethical reasoning. It should be emphasized that every dental practitioner will be a DPH professional at some times, as s/he considers issues that affect the entire community.

Competency Addressed:

Demonstrate the ability to incorporate ethical reasoning and actions that promote culturally competent oral health care to individuals and populations

Course Objectives

On successful completion of this course, students will be prepared to:

Recognize the similarities and differences in the mission of dental practitioners versus the dental public health practitioner and how to respond to common ethical issues facing each.
Describe the principles and values underlying public health and dental public health and compare to those for dental practitioners.
Demonstrate how the Code of Ethics developed for dental practitioners will differ from that for dental public health practitioner.
Describe and apply a framework for analyzing the decisions and actions to be made by dental public health professionals.

Lecture 1:Introduction to Ethics

Present the principles of ethics generally recommended for a health provider(Dentist, Dental Hygienist) and for a public health professional. Demonstrate how the mission of the DPH profession suggests different values, principles, and expected actions than a health care provider treating the individual patient. Recognize how federal and state agencies, and professional organizations work together to govern the profession. Consider what elements must be present to generate an ethical dilemma.

Class discussion of Dr. Miguel Garcia and pediatric patient death case

Please allow at least 20 minutes for a discussion of the Dr. Garcia Case.

You may want to start the discussion by asking if the students think this situation represents an ethical dilemma. You might select 2-3 students who say Yes and 2-3 who say No to form two teams and begin the case discussion by asking them to explain how they substantiate their decision that it is an ethical dilemma.

As you lead the discussion of the death of a child, the following points should be brought out:

Ethical Dilemmas: Remember, an ethical dilemma must have positive moral considerations on either side of the alternative options; neither side is obviously correct; and if one acts on one side there may be undesirable side effects brought about. For the Dr. Garcia situation, there is no positive moral stance for the actions that Dr. Garcia took. Dr. Garcia and the treating dentist conspired to destroy elements of the dental chart, to prevent the appearance of negligence. This is not only unethical, it is illegal to destroy or alter a patient record. Did Dr. Pham have an ethical dilemma? Could Dr. Pham have refused to destroy the chart, given that Dr. Garcia, her supervisor told her to do so?
Definition of a DPH professional: Dr. Garcia’s occupation is as a manager of a proprietary health clinic, with a dual responsibilityto manage the clinic to generate profit, often by controlling access and utilization to dental services, and to assure that excellent dental care is provided to patients. He is not a DPH professional. However, a DPH might be a director of a Federally Qualified Health Clinic because the mission there would be to provide as much quality health care as possible within the federal and state support available. The FQHC may also have a variety of outreach activities to assist in getting prevention to the most number of people, even if direct services are not available to all.
Quality health care: This case demonstrates the overlap, for a health care provider, between the ethics of a DPH professional and that of a health care provider. As said above, Dr. Garcia has a dual responsibility as manager to assure quality care within the clinics he manages. Is Dr. Garciaasserting his responsibility to assure quality care for clinic patients? According to expert witness, Dr. Richard Mungo, the care provided in offering the sedation and the use of the papoose board were not within the standards of care.
Justifiable Criticism:Is Dr. Richard Mungo violating the ADA Code of Professional Conduct Section 4: Justice, item 4C Justifiable Criticism, in accusing Drs. Garcia and Pham of negligence in a court of law? According to the ADA Advisory Opinion, “Expert Testimony. Dentists may provide expert testimony when that testimony is essential to a just and fair disposition of a judicial or administrative action.” Thus, the action that Dr. Mungo took is not only allowed, it is required, if, in his honest professional opinion, the care that Dr. Pham and Dr. Garcia took was not consistent with the US standard of care. Again, this case emphasizes the dual oversight on ethical guidelines that DPHers will have, from their professional organization (ADA, ADHA, AGD, etc) and that of the Public Health Leadership Society.

Lecture 2: Application of Ethical Issues on Dental Public Health decision-making.

Present some common ethical issues that arise for DPH professionals. Discuss any local examples that may have come up in the news. Present the Principles for the PH Leadership Society that are based on the values learned last session. Discuss how each relates to the DPH responsibilities. Highlight differences between the DPH responsibility and that of a health care provider treating the individual patient. Discuss the proposal to remove high sugar drinks from the middle school vending machine. Close by offering a framework for ethical reasoning that may aid in the selection between various alternatives and implementation DPH programs.

Class discussion: Vending Machines Found in Most Middle Schools

Please allow at least 20 minutes for a discussion of the Vending Machine Case. This case may be used in a number of modules, Principles of Dental Public Health, Prevention, Advocacy, and Oral Health Literacy in addition to the course on Ethical Reasoning.

You may want to start the discussion by asking for student volunteers to participate in a panel discussion about how, as the local Dental Director for the city they would advise the School Board, taking into consideration their health provider and DPH roles. You could also invite community leaders to participate in a discussion in class, for example, someone from the Parent Teacher Association, the School Board, a school nurse, and/ or a dentist or dental hygienist.

As you lead the discussion, the following points should be brought out:

1.Program goals and alternatives:You, a DPH leaderhave been asked to advise the school board on what would be the best action to take, whether to remove all drinks that are high in sugar, or to leave them in place and educate the middle school students about the risks of obesity and diabetes from consuming high sugar products. Are both of these program alternatives that a DPH provider might recommend? If not, why?

2.Program effectiveness: How effective would each of these programs be in achieving the stated aim, to reduce the risk for middle schoolers for obesity and type 2 diabetes? Is there sufficient evidence that high sugar drinks cause obesity or diabetes to endorse this program? Do you need to know information on effectiveness of the program in order to make an ethical decision? How would you find such information?

3.Autonomy vs. Beneficence: This is a true ethical dilemma because the principles of autonomy (right to choose) and beneficence (doing good for the community patient) are in conflict. What principles relates to your DPH decision to remove the drinks? What principle relates to the option to educate the students to make their own decision? The decision to remove the drinks effectively makes the student’s decision for him or her. You, as the DPH professional are promoting population health and exercising the principle of beneficence, in that you are trying to do ‘good’ for the children. However, you are putting the principle of paternalism (‘father or DPHer knows best’) ahead of the PH Leadership Society principle of “achieving the community’s health while respecting the rights of individuals (autonomy), in that you feel you must make the decision and that the middle school students are incapable of understanding an education message and making such a decision. Which principle do you think is more appropriate in this situation, and why? If this were an elementary school would you have made the same decision? Why?

4.Understanding of DPH, School Boardroles in the ethical reasoning:What is the role of the School Board in this decision? What is the DPH professional’s role? Is the board asking you, the DPH professional to make the decision, or to advise what the objective information on program effectiveness and ethical considerations are? Do you have a responsibility to advocate for a community perspective as a DPH leader? Why, or why not?

5.PHLS Values (Community collaboration, public trust, public discourse) in action:Is part of your DPH role to recommend that a public education campaign take place so that parents can be informed and participate in the decision-making? If so, how might that take place? Could a third set of volunteers (assuming the role of the School’s Parent Teacher Association) join the student School Board and the DPH professional volunteers to join the ethical debate on assuring there is appropriate public discourse? How do you justify the decision using the ethical principles of Public Health Leadership Society in your response?

Related discussion or activities:As you complete the above case discussion, or for an individual or team homework assignment you might raise the question ofhow the ethical reasoning might vary if the situation was an elementary school or high school, or if a Medicaid parent is giving an infant a milk bottle when the child goes to bed at night, or if a parent decides to not allow a child to participate in a school sealant program. The student would follow the framework for ethical reasoning and how to justify PH programs that conflict with individual liberty; lay out the issues and a possible solution in one page. Discussion could also include State of California Assembly Bill 459, introduced in February 2013 bringing into law the types of food that can be provided in vending machines.

Lecture 3:Application of Ethical Reasoning on DPH decision making for Disease Prevention and Community Health Promotion.

Discuss the DPH responsibility to encourage healthy behaviors. Review briefly the framework for considering how to justify DPH programs that conflict with individual liberty and how to reduce the ethical risk of a proposed DPH program. Then apply this to a situation where two counties debated whether or not to have water fluoridation.

Case Discussion: Pinellas County Commission votes to stop putting fluoride in water supply and Hillsborough’s Plant City voted to implement fluoridation:

Please allow at least 15 minutes for a discussion of the Pinellas Fluoridation Case.

As you lead the discussion, the following points should be brought out:

Program goals and alternatives: You are a practicing health care provider (Dentist, Dental Hygienist) in Pinellas County and read in the Tampa Bay newspaper that the County Commission plans to vote to remove fluoridation from the water supplyafter 7 years of use in early October. What action would you take to fulfill your responsibility? Are there alternatives to water fluoridation that you will suggest to the County Commissioner? With whom do you communicate this information?
Understanding the roles of the DPH, the practicing health care providers, and the County Commission in the ethical reasoning and decision-making: What is the role of the health care provider in this decision? What is the DPH professional’s role? If the county/ city has no Dental Director might you be charged to function in that role as a DPH professional? Is the County Commission asking you and/or the DPH professional to advise them in making the decision, or in providing programmatic information on effectiveness and ethical considerations? Should the County Commissioner ask for input and advice? Is advocacy part of the joint ethical responsibility of health care providers in the community?
Program safety and effectiveness:How safe is water fluoridation? How effective is a water fluoridation program in reducing caries? What principles of the ADA Code of Ethics and Professional Conduct and the PH Leadership Society are applicable to the discussion on safety and effectiveness? How would you frame your argument to convince the County Commission that they should vote against defluoridating?
Advocating and empowering community members: Do you need to know information on disparities in oral health status in order to make an ethical decision as a practicing health care provider? What about the wishes and values of the community? How would you find such information? Who would you contact? Is there evidence that appropriate community interaction took place? Was the health community actively engaged in the decision-making process? Was this the correct decision? Did the notice on the Pinnellas website provide adequate information to the community?

And at the same time, Hillsborough County’s Plant City votes to implement fluoride in the water supply:

At the same time that Pinellas County defluoridated their community water supply, Plant City, in Hillsborough County discussed whether to implement a plan to fluoridate, and voted to implement. In the ADA November 7, 2011 article, Dr. Oldham discusses his role as a practicing dentist in assuring that the city council members had the information necessary to make a final decision. Discuss the similarities and differences between these two situations and how the actions of the health care providers and DPH leaders functioned in this situation.

As another participant who was key in the decision-making, consider the value of the Fluoridealert issued by Paul Vanderploog, Director from the Hillsborough County Water Resource Services issued calling out“As a public utility which provides high-quality drinking water to more than 350,000 people, Water Resource Services receives numerous advisories, statements, position papers, opinions and articles from a wide variety of sources. Our staff carefully evaluates each new development in the industry. Medical issues in particular can be extremely complex and confusing, and difficult to put into context by anyone other than medical professionals. That is why, in such matters, we rely on medical experts - in particular, the Hillsborough County Health Department - to evaluate the validity of the material and determine what message should be relayed to the public. Utilities are not allowed to make such judgment calls themselves. To do so would violate procedures, protocol and laws established to safeguard our customers.”

If time permits, a Youtube clip from the Rachel Maddow show presents news reporting on how a Republican candidate backed anti-fluoridation. This could be used for a class discussion on how the topic of fluoridation often flows far from the science to people’s beliefs on individual control, politics, and trust in health care providers.

Moving on with a discussion of two other public health tools, collection and use of epidemiologic data & population surveillance. The case for such screening and collection of data for oral cancer is presented, and the question is raised as to how to apportion the DPH professional’s time and resources for collection of data and screening versus programs designed to reduce alcohol and tobacco use.

As you lead the discussion, the following points should be brought out:

Program Effectiveness and selecting from program alternatives: Should studies of the effectiveness of community based interventions be deferred until clinical effectiveness in reducing morbidity and mortality has been established? Is the community empowered or benefited when a DPH implements collection of cancer data if such data does not improve program outcomes? Is there value to data collection that serves some or all members of the community? Should the community approve the implementation of cancer registries?
Ensure the professional competence of professionals:What roles should various health professionals and DPH professionals play in early detection of oral and pharyngeal cancers?
How should effort and other resources be allocated among strategies designed primarily to prevent these cancers (e.g., tobacco use prevention) versus strategies aimed at early detection? To what extent do early detection efforts reinforce messages about reducing tobacco and alcohol use?

Lecture 4: Application of Ethical Reasoning on DPH decision making for considerations in human subject research and the DPH and health care professional’s responsibility to report cases of elder abuse.