Ethics, values and the law

To grasp the essential nature of professional ethics, it is necessary to achieve such a separation, between the law, on the one hand, and ethics on the other

Law

Although the precise structure of legal systems around the world varies in many respects, there does tend to be a set of common principles.

In general, one sees a separation between the relationship of an individual (or corporate organisation) to the state (often crystallised into criminal law), and that between one citizen and another (civil law). Different jurisdictions have different approaches to the law which may be codified by law, statute or case law as appropriate.

Criminal law identifies the requirements of personal behaviour in relation to society, and will encompass a wide spectrum of offences against what society considers to be acceptable. These range from obvious offences such as murder, to various kinds of assault, public disorder, race relations and discrimination, theft and fraud, to health & safety legislation, employment law, defamation, and law relating to land and property, transportation, goods and services etc. It is usually based on specific acts, regulations and other statutes.

Civil law applies to cases which are brought by one citizen against another. Examples would be allegations of breach of contract, or negligence (including medical negligence). In each of these situations, there is a statutory point of reference, ie. an Act or a Law, or a set of regulations made in order to give practical effect to such legislation. One can therefore refer to the text of such legal (statutory) instruments and interpret it in the context of a given set of circumstances.

There is, however, an inherent difficulty in that laws are made in order to achieve certain objectives, and usually with particular applications in mind. They are created at a fixed moment in time, but at some future moment a situation can arise that had not been envisaged or anticipated when constructing the original text of the law. The implications of this dilemma are perfectly summarised by the text which appears below, which is an extract from an article which was published many years ago in the Law Quarterly Review.

The Lawyer, like the Theologian, is faced with a number of texts that he regards as authoritative and that are supposed to settle any question that can conceivably arise. Each text was once drawn up by someone who presumably meant something by it; but once the document has left the author's hand, it is the document which matters, not any unexpressed meaning that still remains in the author's mind. For the lawyers, the words of the document are authoritative as words, and there is no possibility of obtaining further information from the author, either because the author is dead or because of the rules of evidence precluding reference to him.

What this means is essentially that we can refer for guidance to whatever laws and regulations exist in relation to the issues under consideration. Once the law is passed, all that matters is the actual words it contains i.e. the text of the legislation, even though we may be dealing with a situation that its author might never even have contemplated.

Usually, we will find enough detail in the text of the law to tell us how we should act - or more pertinently in many cases, how we should not act. Sometimes, we will need to interpret the text of the regulations and apply it in an intelligent fashion to the situation we find ourselves in. The very fact that so many barristers and lawyers are kept in gainful employment, should leave no room for doubt that there will often be different ways to interpret and apply the same law.

Where there are acts and statutes, laws and regulations to point the way, then, there is at least some certainty and direction. But there will be many other situations in our professional and personal lives where there is no such certainty - or at least, some room for doubt. Ethics is largely about what happens in between those areas where the law has provided us with clarity and definition - although many ethical principles are also enshrined in legislation, and in violating them we would be acting both illegally and unethically.

Ethics

Ethics is essentially the voluntary framework of guiding principles which brings order and purpose into what would otherwise be a void between laws, on the one hand and a free-for-all on the other. Because ethics are essentially a moral code or a set of principles to guide behaviour, they are different from laws, and have been described as 'allegiance to the unenforceable'. But in the case of dentistry, this is not strictly true because regulatory bodies (Dental Councils and Dental Boards) have the power to suspend or remove a dentist's registration, even when no law has been broken. Professional ethics and conduct is therefore highly enforceable because the dentist's registration is at stake. From this you will deduce that ethical behaviour is mandatory for a career in dentistry and not voluntary.

In understanding the nature of ethics, and their relationship to the law, a useful analogy is that of a wall. The solid bricks or stones represent clearly defined and substantial laws and statutes. Ethics represent the cement or mortar that fills all the voids between the bricks and stones. They help to hold the wall together, and to give it additional strength.

The bigger the voids in between the solid components, and/or the weaker the cement/mortar, the more likely it becomes that the wall will collapse. The strongest and most durable wall is to be found where the optimal balance is maintained between the solid components (the law) and the cement or mortar (ethics) that fill in the gaps.

Values

If 'purpose' describes one's intended destination, then your 'values' are the principles that you will follow while getting there. Values come in different shapes and sizes, and they arise from a plethora of sources - in many cases, long before we get anywhere near a dental school, let alone become a registered dentist.

Examples of values would be:

• Fairness
• Decency
• Respect for the rights of others
• Honesty, trustworthiness, truthfulness
• Treating others as we would hope to be treated ourselves
• Perseverance and dedication (trying your best)
• Kindness
• Reasonableness
• Tolerance
• Responsibility

There are many others, of a slightly different nature such as:

• Understanding and empathy
• Courtesy and politeness
• Strength
• Consistency
• Resilience
• Enthusiasm and positivity
• Energy and work rate
• Openness

A characteristic that one person would consider admirable, might not be viewed in quite the same light by others, and different people will attach different levels of importance to the existence of these (and other) values. One person will see strength, an inflexible commitment and an intolerance of failure as being highly admirable virtues, while another would rate a softer, more accommodating and more flexible style, more highly.

Public expectation

There is a difference, of course, between one's professional and one's personal life. A healthcare professional such as a dentist arguably needs a slightly different set of core values to a political or military leader. What is more important, perhaps, is that the public will expect certain things of doctors, dentists and other healthcare professionals - just as the public expects certain things of Judges, religious leaders, police officers, lawyers, airline pilots, teachers, social workers... and so on. When a person's behaviour falls short of the expected standards, it is often quite easy for us to conclude that this is unacceptable for someone in that position.

Our status as members of a respected profession brings us many privileges that are not enjoyed by people in other walks of life. If we abuse those privileges, we do so at our own peril because a position of trust and respect is much more easily lost, than it is regained after having been lost.

It is only logical that the profession should collectively agree a minimum standard of behaviour and conduct that will not only protect and safeguard patients, but will also uphold the reputation of the profession and its status in society. It is very much in the interests of the profession itself, that patients should be protected in this way, because it helps to maintain public confidence in dentists and those associated with the profession of dentistry.

But we live in a changing world, and the importance which society attaches to certain values, is also changing. It is almost inevitable that each successive generation of practitioners will start their professional careers firmly convinced that they are better than their predecessors in almost every respect, spend the middle part of their careers believing that the latest crop of new dental graduates is sadly lacking in some crucial respect, and will end their careers trying to convince others that they were right on both of the other occasions! It is in the natural order of things that each successive generation believes that standards are gradually falling in the generations that follow. Even if this were to be true, then senior members of the profession must take their share of the responsibility for this, because maintaining ethical standards in the profession is a job for us all, since ethics are a voluntary code of principle generated from within the profession, for members of the profession to follow.

Perhaps the most fundamental of the principles upon which healthcare relies, are the twin pillars that support the patient: dentist (or patient: doctor) relationship, namely:

• Doing good and acting in the patient's best interests (beneficence)
• Doing no harm

The presumption on the part of any patient that they will benefit from, rather than be harmed by, healthcare provided for them is a natural one, and it explains the sense of hurt and disappointment (and sometimes anger) that accompanies instances of clinical negligence.

Our medical colleagues face many ethical challenges that we in the dental profession are mercifully spared, and some of them are extremely complex. At either end of the cycle of human life, some acutely difficult ethical principles are involved; at one extreme, the right to life and at the other, the right to die with dignity. In between, however, we face many of the same pressures and many of the same dilemmas as our medical counterparts. In dentistry, just as in medicine, a patient may be insistent upon a certain treatment, which the clinician knows to be against the patient's best interests. The ethical obligation to act in the patient's best interests might well conflict with the patient's right of selfdetermination (autonomy). It is, after all, their body and their right to decide what happens to it, but there remains a tension between two entirely separate ethical principles.

But it is also right and proper that we should anguish over some of these decisions. The more often we place ethical issues in the balance of clinical decision-making, and debate them with colleagues, the more they become part of our mainstream thinking. This is healthy and constructive.

As professional people we must remain accountable not only for our adherence to the law but also for the values and ethics that characterise our approach to dentistry and to the professional standards that we aspire to. All the more reason, therefore, that we should invest as much time pondering these issues, and reminding ourselves of their importance, as we spend in learning and practising new clinical techniques.

In search of ethics

The duties of care to protect a patient's life and health at all times, to respect their autonomy to make informed choices about what happens to them and to do so fairly and without prejudice, are widely accepted as the fundamental ethical principles governing all health care. Almost every clinical decision has an ethical and legal content, as well as the more extraordinary situations that can arise in dentistry. This series will focus specifically on essential ethical concepts which should then be interpreted in the light of the legislation applicable in the locality in which they practice.

So where should we look when we are searching for the source of our ethical knowledge? For most of us, our value systems are largely a product of our upbringing. Parenting and family values have a major part to play - sometimes as role models, but sometimes precisely the reverse. In the latter case, the formative pressures upon an individual may result in the rejection of the values they 'inherited', and their replacement with quite different values.

Peer influences can also be extremely powerful, as can that of an admirable 'mentor'; someone that a child, teenager or young adult looks up to and seeks to emulate. Faith and religion can be another important source of values and ethics.

By the time someone becomes an undergraduate dental student, many would say, it is already too late to influence their values and ethics to any great extent. Today's young people face extraordinary pressures, often of a kind which earlier generations of dentists fail to understand, or on a scale which they can't (or won't) appreciate.

The financial and peer pressures that young graduates are faced with today are massive and debilitating. Society is different; attitudes towards the profession and professionals in general are different, and in a number of respects the social structure and dynamics of life in many countries around the world have eroded a sense of vocation for professions such as dentistry.

There are many other groups of people who might be in a position to influence the development of ethical values, including:

• Undergraduate teachers
• Those who employ, manage and supervise young dentists in the early years after they qualify
• Practice owners and supervisors, or those in positions of responsibility or authority
• Colleges, Academies and specialist societies
• Dental associations and other representative bodies
• Dental Boards and Dental Councils

The end of paternalism

In the past, many of the ethical principles seen in medicine and dentistry reflected a somewhat paternalistic approach to healthcare and its delivery. There was little public knowledge of medicine and medical science, and a patient's respect for doctors was based - in part at least - on the fact that he was, literally, placing his life in the doctor's hands. It was blind trust and faith in the doctor's greater knowledge and ability, and much of professional ethics was designed to underpin the massive responsibility that fell on the shoulders of doctors (and other healthcare professionals), as a result of this inherent imbalance.

Autonomy

We have since seen a dramatic shift towards the existence of a more informed, articulate, and questioning public, who have greater rights and remedies at their disposal if they are aggrieved. They rightly expect to be informed and participative partners in decisions which affect them, and it is this mutual respect for the rights and opinions of the other, that has shifted the balance of professional ethics - in some respects at least - in recent years.

Discussion

Having an ethical framework for our professional (and personal) lives is both important and enriching. The choices we need to make will not always be straightforward, and a professional career throws up many difficult situations and conflicts - especially in a field such as healthcare.

In our busy professional lives, many of us do not spend a great deal of time reflecting upon our values, why we hold them and where they come from. Nor do we consciously refer to them when difficult decisions need to be made.

Professional ethics do not lend themselves to the same well circumscribed 'user's guide' that the Law gives us. In many cases, we act ethically simply by following the law. In other cases, the law leaves us stranded and it is on these occasions that doing the right thing will not always come naturally. We will make correct and ethical decisions more often, if we have already spent time thinking through our ethical stance on the issues that will arise, again and again, during our professional life.

First principles (such as placing the interests of patients above our own personal interests) are certainly helpful, but not every professional dilemma can be distilled down to such convenient building blocks. Many ethical dilemmas have nothing to do with the best interests of patients.

Our worth as human beings is the sum total of our values. One such value is the extent to which we respect and follow the law. As professional people, our ethical standards will be dependent upon these values, and also the extent to which we see them as being less important, equally important or more important than the technical quality of the clinical treatment we carry out. The series of Ethical Modules of which this is a part, is designed to re-establish the place of ethics alongside the pursuit of clinical excellence.

Ethics may be time-honoured, but they are certainly not old-fashioned. The challenge is for more senior members of the profession to help young dentists develop a practical appreciation of how traditional and ethical principles fit into and around everything they do in their professional and personal lives today.

This ethical context is the key to helping young dentists to embrace and apply these values which, ultimately, are all about attitude, approach and decision-making. Everything else in dentistry (such as the delivery of the treatment itself) flows from that, because treatment without ethics it is diminished in its worth. There is a danger that the present focus upon clinical standards will encourage the pursuit of clinical excellence at all costs, without proper consideration of the necessity and appropriateness of the treatment, or of a careful consent process.

Summary

Reflecting upon our own values and ethics, and setting young dentists on the right road doesn't just make good sense; it is a professional responsibility that we all share.