Keerut Oberai looks at two more types of ethical theories, their advantages, disadvantages, and uses in dentistry.

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Introduction

Previously in this series, we considered the role of ethical theory before turning our attention to utilitarian ethics. In this part, we will look at two more ethical theories - duty-based ethics (sometimes known as deontological or non-consequentialist ethics) and virtue ethics. Both ethical theories, which are very different in nature, are used in definitions and models of professionalism in dentistry. As with the previous section, we will consider the ethical theory, its advantages and disadvantages and its uses in dentistry.

Duty-based ethics (non-consequentialist ethics)

Duty-based ethics claims that whether an action is right or wrong does not depend on the consequences of the action. This contrasts with consequentialist ethics, which we explored in the previous part of this series, which claims that whether an action is right or wrong depends on the consequences that it brings about. Instead, duty-based ethics provides us with moral rules which we ought to follow. Acting in accordance with these rules is moral and in contrast breaking them is immoral.

Immanuel Kant most famously advocated for this system of ethics. He claimed that it was our duty to act in accordance with a universal moral law. Rules which accorded with this moral law he called categorical imperatives. Kant claimed that these categorical imperatives ought to apply to all rational agents and therefore have the quality of being universal. He summarised this stating, 'act only according to that maxim whereby you can at the same time will that it should become a universal law'.1 In addition, we ought to act in accordance with categorical imperatives regardless of our own preferences and motivations.

In dentistry, duty-based ethical theory is the basis for professional standards of conduct. These are professional rules or standards that we, as dental professionals, ought to follow.

In dentistry, duty-based ethical theory is the basis for professional standards of conduct. These are professional rules or standards that we, as dental professionals, ought to follow. They guide our action both inside and outside of clinical practice. The most prominent of these professional standards is the General Dental Council (GDC) Standards for the dental team which 'sets out the standards of conduct, performance and ethics that govern you as a dental professional'.2 The advantage of duty-based systems of ethics and professional standards is that they clearly set out the expectations of dental professionals and are action guiding. An action guiding ethical principle clearly defines what actions are right and wrong which can be extremely helpful when presented with an ethical dilemma. However, in some circumstances duties may come into conflict. Kant and other duty-based ethicists struggle to come up with an account of how we resolve these conflicts and which rules or duties should take priority over others.

Virtue ethics

Whilst consequentialist and duty-based ethical frameworks consider what is the right action, virtue ethics considers what sort of person we ought to be. This ethical theory was put forward in its most influential form by Aristotle in his work 'Nicomachean ethics'.3 Here, he advocated for a teleological account of ethics which considers the ultimate end or purpose of human beings. He suggested that it was to achieve a flourishing life, which he referred to as eudaimonia.

To attain this, we must adopt a certain set of virtues or characteristics. In doing so, we will habituate towards choosing the right action when presented an ethical scenario. However, which virtues are we to adopt? Aristotle claimed that the virtues which help us achieve eudaimonia exist within a 'golden mean'. In other words, the virtuous characteristic is the one which exists between two extremes. For example, the virtue of courage exists between the extremes of recklessness and cowardice.

When applied to dentistry, virtue ethics tells us what sort of dentist we ought to be. In other words, what virtues we ought to be in possession of to be considered a professional or good dentist. For example, the Royal College of Physicians defines professionalism as 'a set of values, behaviours and relationships that underpin the trust the public has' in the profession.4 When considering professional values these often include virtues such as altruism, trustworthiness, beneficence but also those such as making sure one is maintaining their clinical skills and knowledge.

Virtue ethics, whilst appealing has its critics. The main criticism is that it does not help guide our actions like the previous two ethical theories we have looked at. In other words, it is not action guiding and there will not be a clear answer as to which action to take. For example, what is considered as a beneficent action may not be clear as in the case of euthanasia - is it better for patients to be kept alive but suffer or be allowed to die on their own terms. The answers to such dilemmas are not always clear when virtue ethics is applied.

Professionalism in dentistry

Professionalism in dentistry, and indeed in healthcare, has changed drastically over the last 50 years. In the past, professionalism was based on a paternalistic model in which the dentist told the patient what treatment they needed and what was in their best interests. Instead, we now have an emphasis on autonomy and the patient being a partner is decision making, determining their own best interests. Professionalism is therefore something which is dynamic, and which will continue to evolve and develop over time. Indeed, we have already seen novel challenges to professionalism such as the emergence of social media which is still a relatively new phenomenon.

In 2020, Cardiff University and the General Dental Council (GDC) produced a mixed-methods research study on the topic of professionalism in dentistry.5 The study highlighted the importance of communication and patients feeling that they were 'being treated by a practitioner with 'safe' hands'.5 Dentists themselves were also able to input their opinion on the subject. Interestingly, many dentists reported that having to deal with financial transactions was something which they often found difficult. This is something which is unique to dentistry with most of our healthcare colleagues working with patients who do not pay for their medical care.

Duty-based and virtue ethics can help us in ethical dilemmas and help us to understand what it means to be professional.

Anecdotally, many dental practitioners are concerned that, even if they have act in a way which they perceive to be ethical and if they have done their best, a complaint may still arise. This is a concern which is no doubt linked to the increasing fear of litigation in dentistry. The study discussed this stating 'dental professional groups discussed the impact of regulations, financial pressures, and isolation on professionalism. They presented complaints as a serious issue facing every dentist and talked about "defensive dentistry" and a "climate of fear"'.5

The study also conceded that professionalism in healthcare and indeed in dentistry can be a difficult topic to clearly define. Furthermore, we may be presented with nuanced cases in which it is difficult to know what the right answer is. This was confirmed in the study which found that:

'Professionalism is developed through observation and reflection and can be challenging to assess. New dentists learn from observing seniors. Insight and reflection were viewed as important throughout dental training and professional practice.'5

For the most part, we are innately aware of what counts as professional behaviour. However, there will always be challenges and nuanced cases. This is where having an ethical theory, such as those we have looked at so far in this series, can provide a foundation to help us navigate our way through these challenging scenarios.

Conclusion

To conclude, duty-based and virtue ethics can help us in ethical dilemmas and help us to understand what it means to be professional. Duty-based ethics provides us with a set of rules or duties which we ought to follow, and which help guide our actions. In contrast, virtue ethics tells us what sort of dentist we ought to be and what characteristics or virtues we ought to possess. These ethical theories help underpin our professional behaviour and judgements in daily clinical practice. Both can help us in navigating the nuanced and sometimes complex professional challenges that we face in everyday practice. Whilst they may not provide an exact answer, they can act as a framework or foundation on which to build on.