Respect

Such an intuitive response most likely stems from an existing ethical sensibility that has already been accepted. It should also make it somewhat easier to understand that respect for another individual is not a single concept, but a combination of the principles of autonomy, fidelity and veracity, combined with an intention to do no harm. This module will consider all of these aspects of the professional relationship formed between the clinician and the patient. Respect for the Law is covered in Ethics module 1.

Respect is sometimes loosely used as a synonym for politeness or manners, both of which are behavioural responses, whereas respect is really an attitude of mind which can be expressed in a variety of different ways (both verbal and non-verbal). By adopting a respectful attitude to your patients you will protect their dignity, and earn their respect in return. The professional relationship is inevitably enhanced by an approach that recognises each patient as an individual with feelings and sensitivities of their own and which may differ from those of the previous patient and possibly from your own.

It is not necessary to agree with all that a patient believes or feels but it would be unethical to deny them such freedom. Respect does not necessarily imply deference but it does exclude selfish or prejudiced behaviour on the part of the clinician. The concept of respect pre-dates any legislation which may have subsequently been introduced in an attempt to protect the rights of the individual.

Most Dental Boards and Dental Councils around the world issue guidance on professional conduct, which stresses the need to treat all patients with respect and dignity. In some countries these principles are also enshrined in codes of human rights or similar legislation. Consequently, a failure to recognise and address issues relating to ethnicity, religion, sexual preferences, disabilities etc. can have far-reaching professional consequences.

Dignity

Immanuel Kant expressed the view that each person has intrinsic worth and possesses certain rights that others are obliged to respect. The right of an individual to follow their own self-directed choices in life is called autonomy. Such behaviour may not always be dignified (eg. choosing to drink to excess and getting drunk). However the acceptance and understanding exhibited by the healthcare provider who subsequently treats that same individual for an injury sustained whilst they were drunk, demonstrates a respect for autonomous behaviour and also restores some dignity to the situation.

Moreover, when the professional is required to engage with matters such as religion, sexual preference or personal lifestyle, respect for the autonomous decisions made by the patient will ensure that the patient is treated with dignity.

Sometimes, the patient may have no choice in the circumstances which engulf them. Medical conditions and mental illness are rarely the result of an autonomous decision by the patient, although occasionally they can be (an accident involving a car driven whilst intoxicated could result in permanent disability).

Self-respect is the cornerstone of all virtue

John Herschel (1792-1871)

To ensure that such patients receive the same standard of care as every other patient, it may be necessary to modify the way in which dental treatment is delivered.

• easy access to the surgery for users of wheelchairs and walking aids
• large-print post-operative instructions for people who are vision impaired
• taking sufficient time for patients with learning disabilities both when obtaining consent and when providing treatment.

By preserving the standard of care in such cases, the dignity of the patient is both recognised and preserved. Sometimes the effort may not be appreciated by the patient (eg. ensuring a wellmatched porcelain shade is achieved for a sight-impaired patient requiring a crown) but that doesn't excuse the clinician from an ethical obligation.

Sometimes the clinician does not have to adjust the way in which treatment is delivered to ensure that the dignity of the patient is preserved. It can be as simple as checking to ensure that they adopt a non-judgemental approach towards every patient. Such an approach would make it possible for patients with HCV or those living with HIV/AIDS to feel just like any other patient and thereby retain their dignity.

Transcultural issues

As international migration continues to increase, and communities become increasingly multicultural and ethnically diverse, new problems can arise for the clinician as a result of that diversity.

The most striking feature of this development is the realisation that there is no consistent pattern in these problems. Indeed, the only common theme seems to indicate that diversity can lead to misunderstandings, communication problems and on occasions, breakdowns in the professional relationship which have little or nothing to do with the dentistry itself.

The first step in avoiding problems of this kind is to develop a proactive understanding of all those with whom we come into contact in a professional capacity, and whose background is different to our own. Many clinicians do not work in the country of their birth, nor do they use their first language to communicate whilst at work. The same is true of many of our patients, and the staff with whom we work. The nature or location of a practice may be such that a diverse mix of patients presents for treatment.

However, the onus rests on the professional to bridge these cultural, ethnic and potential social divides. The ability to communicate effectively is probably the most obvious hurdle to address, but making the effort to do so - whatever the difficultiesis a demonstration of respect for the patient.

Communication

Language problems when the clinician and the patient do not share a common language, or when one or other party has only a minimal grasp of any common language - can be reduced by the use of interpreting services (often available by creating a conference call between the dentist and the patient in the surgery and an external interpreting service) along with a written treatment plan and information sheets.

Inflection in some languages, the speed/ loudness/tone/timbre/ articulation of the spoken voice, coupled with habitual facial expressions and gestures, can mislead an uninformed observer/listener into assuming that the speaker is being aggressive/rude, uncaring or disinterested, when this is not the case.

Body language there are wide cultural differences in body language, with a different emphasis being placed upon certain postures, signs and gestures in different cultures.

What is entirely acceptable and normal in one culture can be grossly offensive in another.

An understanding of and a sympathetic response to these differences can dramatically reduce the potential risk arising from these issues.

Respect yourself and others will respect you

Confucius (551 BC - 479 BC)

A significant strengthening of antidiscrimination legislation in recent years has reinforced the ethical concept of respect. Professional ethical standards do not tolerate acts of discrimination directed towards the patient. The most commonly cited grounds for discrimination refer to the patient's age, ethnicity, religion, sexual preference, medical conditions or some other disability. In such cases the clinician can be heavily censured for such unethical behaviour. Common complaints have been:

• The patient was refused treatment
• The patient was treated less favourably than other patients.
• The specific needs of a patient were not met or were dealt with grudgingly

It is important to remember that allegations about discrimination may be raised by employees, as well as by patients.

A perceived lack of respect

When relationships break down between patients and the dental team, there may be a perfectly good explanation, which has nothing to do with any lack of respect or discrimination. The same situation can also arise when interviewing potential staff members, or dealing with issues of underperformance within the working environment. But, unless great care is taken to deal fairly and equitably with everyone, regardless of ethnic origin, religion or other issues, there will always be the potential for one's intentions and actions to be misinterpreted and misunderstood.

This is not to say that a clinician is powerless to take whatever reasonable actions they might normally take, if and when they experience difficulties with patients or employees. What is essential, however, is that no individual is treated differently or less favourably, because of their ethnic origin etc.

Some practical points to consider in the clinical setting

• Invest time and effort in developing a better understanding of the ethnic and cultural background of the patients you treat and the staff you employ.
• Provide clear leadership for practice staff by establishing a written practice policy that all patients (and employees) will be treated fairly, equally and with respect, irrespective of their ethnic background etc.
• Be conscious of those situations where your words and actions (or those of your staff) may be misinterpreted as being discriminatory or offensive to someone from a different ethnic background to yourself. Keep meticulous contemporaneous records of any incidents that could give rise to problems.
• Anticipate and avoid situations where misunderstandings could lead to disagreement or conflict.
• Take a lesson from other organisations you deal with, which handle ethnicity or transcultural issues with fairness, sensitivity and respect. If your practice serves a multicultural, multiethnic community, it may be appropriate to select staff whose own background gives them an understanding of these issues, and who can thereby help the practice to provide a much better overall quality of service care and treatments to its patients.
• Take extra care when communicating with patients whose first language is not the normally used in the practice, or those who may be unfamiliar or uncomfortable with the practice systems and procedures involved in delivering dental care, for a variety of different cultural or religious reasons.
• Invite patients to voice any concerns they have regarding the way the practice relates to them. It is far better to deal with these issues within the practice than for them to surface, by default, as formal complaints or similar challenges.

A right to complain

There is no greater test of a clinician's ability to put the needs of their patient first than being confronted with a situation where some aspect of care has failed to live up to expectation. It could be a 'minor' event such as failing to see the patient on time or something that may have more serious consequences such as displacement of a buried root into the maxillary antrum during an attempted extraction.

Whatever the circumstances and no matter how serious or trivial the potential consequences, there comes a point in the communication process where the clinician should say 'sorry'. Songwriters and poets through the ages have explored the difficulty of doing so and many have come to the conclusion that sometimes 'sorry' is the hardest word to say! This is just as true for dentists as the population at large.

There can sometimes be a fear that any apology that is offered amounts to an admission of blame, guilt or even liability. Possibly for this reason many dentists are reluctant to apologise to their patients for any event or incident that fails to live up to expectations.

But the clinician should consider the ethical duty of reparation to make amends for any injury caused to the patient. In recognising the situation to the patient by saying 'sorry' you actively demonstrate a degree of respect for that particular individual.

There is also an opportunity to offer an explanation and a remedy for their problem. In the case of the delay in seeing a patient, mentioned earlier, an apology and an offer to have the receptionist call ahead to their next appointment and alert them to the situation is likely to be enough to resolve the issue. The displaced root is more complex. But after offering an apology and an explanation to the patient, the ability to provide an efficient referral to an oral surgeon can go a long way towards resolving matters.

Always recognize that human individuals are ends, and do not use them as means to your end

Immanuel Kant (172-1804)

Patients respect honesty when dealing with a professional and it would be both foolish and unethical to treat them otherwise.

Research

The Hippocratic ethical tradition commits the clinician to working solely to benefit the patient. Systematic research for more general application might seem contrary to those patient-centred ethics. The Nuremberg Code (following the trial of war criminals in 1949) decided, 'The experiment should be such as to yield fruitful results for the good of society, unprocurable by other methods or means of study'. It also recognises the moral principle of autonomy and idea of consent.

The benefits of research in dentistry may well be recognised but areas of controversy still remain:

1. How can any risk to the subject be justified when the society rather than the subject is the main beneficiary?
2. What to tell the patient in order that their consent is properly informed?
3. Compensation for the subject.
4. Funding provided by manufacturers should not influence outcomes.
5. Accuracy of the data skewed by the motivation of the researchers (possibility of falsification).
6. Plagiarism of original work performed by another researcher.

He removes the greatest ornament of friendship, who takes away from it respect

Cicero (106 BC- 43 BC)

Clearly, a careful assessment of the value of the potential benefits must be made and the clinical trial well designed to ensure the benefits more than justify the risks. Unless the knowledge gained will be of some value, it is not acceptable to ask human subjects to participate in a trial simply to satisfy scientific curiosity or to promote the professional career of the researcher(s).

Attempting to satisfy such a standard will often create conflict between scientists whose arguments will need to be considered by the relevant ethics committee. All research trials should be vetted by such a committee in order to eliminate poor science, wasted efforts and any elements of self-interest that might make the project less than honest. Apart from helping to create the highest scientific standards, the committee's role should also ensure that the contributions made by the patients will ultimately be worthwhile, and any risks are commensurate with the benefits as well as being understood and accepted by the patients.

It almost goes without saying that respect for the patient requires that any research project undertaken should not intentionally cause harm. The concept can also be applied to other animal species.

Fidelity

promises that we make to patients along with any other commitments that are made, whether they are explicit or implied. Of course promises may have greater or lesser degrees of significance, but the breach of an ethical principle is always damaging, whenever it arises.

All of these situations can be significant to a patient regardless of any perceived hierarchy of merit:

• The date a denture repair will be ready.
• The cost of a course of treatment.
• This won't hurt.
• The promise to keep information confidential.

Fidelity is ultimately an expression of respect for the patient.

Veracity

Clinicians are expected to tell their patients the truth and not to tell lies. There is an argument for considering whether the knowledge will be helpful or harmful to the patient.

The question,'Is it cancer doctor?' may require some careful consideration of the individual's circumstances before it is answered. Whilst you should not tell a lie, it might be appropriate to defer a definitive answer until you or a specialist colleague are in a position to answer any additional questions that confirmation might precipitate. Clearly the harm generated by a truthful answer, confirming a positive diagnosis, is difficult to quantify because the patient's reaction will be entirely subjective. The clinician must use their own judgement to balance the benefits against the disadvantages and answer accordingly.

The underlying core that supports veracity is respect for the individual. Honesty and truth are parallel concepts that are discussed in more detail in Ethics module 6.

Conclusion

When dealing with clinical situations, respect for the patient is rarely isolated from all the other ethical principles involved in managing our patients' needs.

Respect a man, he will do the more

James Howell (1594-1666)