PRINCIPLES OF BIOETHICS

GUIDED BY:
PROF DR. HEMANT KUMAR HALWAI
ASST PROF DR. KISHOR DUTTA
ASST PROF DR. SANDEEP KUMAR GUPTA PRESENTED BY:
DR. ROCKEY SHRIVASTAVA
1ST YR JR
DEPARTMENT OF ORTHODONTICS
AND DENTOFACIAL ORTHOPEDICS
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CONTENTS
1. The toothache tree
2. Terminologies
3. History
4. Principles of biomedical ethics
5. Theories of bioethics
6. Ethics tools
7. Ethical issues
8. Informed consent
9. Duties of medical practitioners
10. Ethical practice during the COVID-19 pandemic
11. References
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THE TOOTHACHE TREE

Said to be a cutting from a legendary tree known as
Bangemudha, the chunk of wood that has been put in
place smack in the heart of Kathmandu’s dental district,
which is home to a concentration of orthodontists’
offices, acts as a sort of wishing well. People with
toothaches or other dental ailments visit the site and nail
coin to the tree as an offering to Vaishya Dev, the
Newar god of the toothache. Supposedly there is a teeny
tiny little idol inside of the main hole of the tooth god’s
shrine, although the coins nailed on every part of the log
obscure any view into the burl. In fact, the log is so covered
that none of the actual wood is visible anymore either.
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TERMINOLOGIES
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What is meant by “ethics”?

Ethics are the moral principles or virtues that govern the
character and conduct of an individual or a group.

Ethics, as a branch of both philosophy and theology, is the

systematic study of what is right and good with respect to
character and conduct.

Ethics seeks to answer two fundamental questions:

1. What should we do?
2. Why should we do it?
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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The object of ethics is to emphasize spirit (or intent) rather

than law.

Dental ethics applies moral principles and virtues to the

practice of dentistry.

American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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Types of ethics
• 2 types
▫ DESCRIPTIVE
 the way people view life and their moral interactions
and responsibilities with living organisms in life.
▫ PRESCRIPTIVE
 to tell others what is good or bad, what principles are
most important; or to say something/someone has
rights and therefore others have duties to them
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What are codes of ethics?

• Many dental organizations have published codes of
ethical conduct to guide member dentists in their
practice.
• For example, the American Dental Association has had a
Code of Ethics since 1866.
• A code of ethics marks the moral boundaries within
which professional services may be ethically provided.
• Codes of ethics and professional guidelines have quasi-
legal force; non-compliance can result in sanctions from
censure to loss of professional status
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The Nepal Medical Council has in accordance with the

Nepal Medical Council Act 1964, passed a medical Code of
Ethics & Professional Conduct 2017, which all doctors
registered under it, are to abide by.

Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
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Oath:
The following oath should be read and agreed upon by the applicant at the
time of registration:
1. I solemnly pledge myself to dedicate my life to the service of
humanity.
2. Even under threat and duress I will not use my knowledge contrary to
the norms of humanity.
3. I will maintain the utmost respect for human life right from the time
of conception as per the laws of the land.
4. I will not allow consideration of age, sex, religion, nationality,
ethnicity, politics, or social standing to intervene between my duty
and my patient.
5. I will carry out my professional duties with conscience and dignity.

Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
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6. The health of my patient will be my first consideration.

7. I will respect the secrets of my patients confided in me.
8. I will give to my teachers the respect and gratitude that is their
due.
9. I will maintain, by all means in my power, the honour and noble
traditions of the medical profession.
10. I will maintain utmost rapport with my professional colleagues. I
make these promises solemnly, freely and upon my honour.

Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
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Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
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Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
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What is a “profession”?
A profession has been defined as an occupation involving
relatively long and specialized preparation on the level of
higher education and governed by a special code of ethics.

The constructive aim of a profession is the public good.

Dentistry is recognized as a profession.

American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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Four key features of a profession

1. A profession must possess an important and exclusive
expertise;
2. A profession must possess an internal and external
structure, including a community of experts mutually
recognizing each other’s expertise and institutionalization of
this relationship in a formal organization;
3. A profession’s clients routinely grant its members extensive
autonomy in practice of the profession, and dentistry as a
profession is also largely self-regulating;
4. Membership in a profession implies the acceptance by the
member of a set of norms of professional practice or
professional obligations
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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What is a “professional”?
A professional is a member of a profession. Four qualities
have been attributed to those who practice a profession:

1. A professional has respect for human beings;

2. A professional is competent;
3. A professional has integrity;
4. A professional’s primary concern is service, not
prestige or profit

American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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What is “professionalism”?
Professionalism relates to the behavior expected of one in
a learned profession.

Professionalism has been viewed as that quality of conduct

and character that accompanies the use of superior
knowledge, skill, and judgment, to the benefit of another,
prior to any consideration of self-interest.

American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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Eight categories of professional obligations

Chief Client—The chief client is the person or set of persons whose well-
being the profession and its members are chiefly committed to serving;

Ideal Relationship Between Dentist and Patient—An ideal relationship

is based on mutual respect and recognizes that the dentist and patient
both bring important values to the professional setting;

Central Values—The focus of each profession’s expertise is a certain set

of values, and each profession is obligated to work to secure these
values for its clients;

Competence—Every professional is obligated to acquire and maintain

the expertise necessary to undertake professional tasks;
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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Relative Priority of the Patient’s Well-being—While the well-being of

the patient is to be given considerable priority, it is not to be given
absolute priority;

Ideal Relationships Between Co-professionals—There does not seem to

be any one account of ideal relationships between dentists and their co-
professionals because so many different categories must be considered,
but there are professional obligations to co-professionals;

Relationship Between Dentistry and the Larger Community—The

activities of every profession also involve relationships between the
profession as a group or its members and the larger community and
nonprofessional groups and others within it;

Integrity and Education—These are subtle components of conduct by

which a person communicates what he or she stands for, not only in the
acts the person chooses, but also both in how those acts are chosen and
in how the person presents to others in carrying them out
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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What is formalism?
moral judgments in terms of their logical form (e.g., as
"laws" or "universal prescriptions") rather than their
content (e.g., as judgments about what actions will best
promote human well-being)
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Compassion—

Compassion requires caring and the ability to identify with

the patient’s overall well-being. Relieving pain and
suffering is a common attribute of dental practice. Acts of
kindness and a sympathetic ear for the patient are all
qualities of a caring, compassionate dentist.

American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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Competence—

The competent dentist is able to diagnose and treat the

patient’s oral health needs and to refer when it is in the
patient’s best interest. Maintaining competence requires
continual self-assessment about the outcome of patient
care and involves a commitment to lifelong learning.
Competence is the just expectation of the patient.

American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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Integrity—

Integrity requires the dentist to behave with honor and

decency. The dentist who practices with a sense of integrity
affirms the core values and recognizes when words, actions
, or intentions are in conflict with one’s values and
conscience. Professional integrity commits the dentist to
upholding the profession’s Codes of Ethics and to
safeguarding, influencing , and promoting the highest
professional standards.
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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Tolerance—

Dentists are challenged to practice within an increasingly

complex cultural and ethnically diverse community.
Conventional attitudes regarding pain, appropriate
function, and esthetics may be confounded by these
differences. Tolerance to diversity requires dentists to
recognize that these differences exist and challenges
dentists to understand how these differences may affect
patient choices and treatment.
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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HISTORY
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History of Bioethics
FRITZ JAHR
▫ Coined term Bioethics in 1926
▫ Article : Bioethical Imperative
(regarding scientific use of animals and
plants)

Van Rensselaer Potter

American Biochemist
Coined the term Global Ethics (1970)
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History of Medical Ethics

• Hippocratic oath
• 1st code of medical ethics
• Formula comitis acrhiatorum
• Published in 5th century
• During the reign of Ostrogothic king ‘Theodoric the Great’
• Medieval and early modern period
• Ishaq ibn Ali al-Ruhawi wrote(conduct of physician) – 1st book
dedicated to medical ethics

The term medical ethics first dates back to 1803, when English
author and physician Thomas Percival published a document
describing the requirements and expectations of medical
professionals within medical facilities.
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History of dental ethics

• In the histories of dentistry, some mention is made of the
licensing of tooth-drawers, and those who provided
dental healthcare before the term Dentist started to
become general in the late eighteenth and early
nineteenth centuries.
• The Roots of Dentistry edited by Christine Hillam in
1990 for the British Dental Association, and the
introduction to the chapter makes it clear that some of
those who treated teeth and toothache were licensed by
the Company of Barber Surgeons of London, or by their
local bishop
Bishop M, Gelbier S, Gibbons D. Ethics–dental registration in the seventeenth and early eighteenth century. British dental
journal. 2001 Oct;191(7):395-400.
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PRINCIPLES OF BIOMEDICAL
ETHICS
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Principles of Biomedical Ethics

• Beauchamp and Childress (1979)

▫ Autonomy
▫ Beneficence
▫ Non-maleficence
▫ Justice
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Principles of dental ethics

American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official
advisory opinions revised to November 2018.
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PATIENT AUTONOMY (“self-governance”)

This principle expresses the concept that professionals

have a duty to treat the patient according to the patient’s
desires, within the bounds of accepted treatment, and to
protect the patient’s confidentiality.

Under this principle, the dentist’s primary obligations

include involving patients in treatment decisions in a
meaningful way, with due consideration being given to the
patient’s needs, desires and abilities, and safeguarding the
patient’s privacy.
American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official
advisory opinions revised to November 2018.
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NONMALEFICENCE (“do no harm”)

This principle expresses the concept that professionals
have a duty to protect the patient from harm.

Under this principle, the dentist’s primary obligations

include keeping knowledge and skills current, knowing
one’s own limitations and when to refer to a specialist or
other professional, and knowing when and under what
circumstances delegation of patient care to auxiliaries is
appropriate.

American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official
advisory opinions revised to November 2018.
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BENEFICENCE (“do good”)

This principle expresses the concept that professionals have a duty to act
for the benefit of others.

Under this principle, the dentist’s primary obligation is service to the

patient and the public-at-large. The most important aspect of this
obligation is the competent and timely delivery of dental care within the
bounds of clinical circumstances presented by the patient, with due
consideration being given to the needs, desires and values of the patient.
The same ethical considerations apply whether the dentist engages in
fee-for-service, managed care or some other practice arrangement.
Dentists may choose to enter into contracts governing the provision of
care to a group of patients; however, contract obligations do not excuse
dentists from their ethical duty to put the patient’s welfare first.
American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official
advisory opinions revised to November 2018.
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JUSTICE (“fairness”)
This principle expresses the concept that professionals
have a duty to be fair in their dealings with patients,
colleagues and society.

Under this principle, the dentist’s primary obligations

include dealing with people justly and delivering dental
care without prejudice. In its broadest sense, this principle
expresses the concept that the dental profession should
actively seek allies throughout society on specific activities
that will help improve access to care for all.
American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official
advisory opinions revised to November 2018.
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VERACITY (“truthfulness”)
This principle expresses the concept that professionals
have a duty to be honest and trustworthy in their dealings
with people. Under this principle, the dentist’s primary
obligations include respecting the position of trust
inherent in the dentist-patient relationship,
communicating truthfully and without deception, and
maintaining intellectual integrity.

American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official
advisory opinions revised to November 2018.
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THEORIES OF BIOMEDICAL
ETHICS
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Theories on Bioethics

• The Deontological Theory

• The Utilitarian Ethical theory
• The Rights Ethical Theory
• The Casuist Ethical Theory
• The Virtue Ethical Theory
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The Deontological Theory

• states that people should adhere to their obligations and

duties when analysing an ethical dilemma
• Shortcoming- there is no rationale or logical basis for
deciding an individual's duties.
• Since deontology is not based on the context of each
situation, it does not provide any guidance when one
enters a complex situation in which there are conflicting
obligations 
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The Utilitarian Ethical Theory

 
• Founded on the ability to predict the consequences of
an action
• To a utilitarian, the choice that yields the greatest benefit
to the most people is the choice that is ethically correct.
• Benefit -utilitarian can compare similar predicted
solutions and use a point system to determine which
choice is more beneficial for more people. This point
system provides a logical and rationale argument for
each decision and allows a person to use it on a case-by-
case context 
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UTILITARIAN THEORY
ACT RULE
• Adheres exactly to definition • Concerned with fairness
• Achieving the maximum good, not • Benefits the most people but through
always concerned with justice, the fairest and most just means
beneficence or autonomy for an available.
individual if oppressing the individual • Values justice and beneficence at the
leads to the solution that benefits a same time
majority of people
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The Rights Ethical Theory

• Rights set forth by a society are protected and given the

highest priority
• Rights are considered to be ethically correct and valid
since a large or ruling population endorses them
• Major complication on a larger scale, however, is that
one must decipher what the characteristics of a right are
in a society
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The Casuist Ethical Theory

• Compares a current ethical dilemma with examples of

similar ethical dilemmas and their outcomes
• This allows one to determine the severity of the
situation and to create the best possible solution
according to others' experiences.
• Drawback - there may not be a set of similar examples
for a given ethical dilemma
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The Virtues Ethical Theory

•  Judges a person by his character rather than by an
action that may deviate from his normal behaviour.
• It takes the person's morals, reputation and motivation
into account when rating an unusual and irregular
behaviour that is considered unethical.
• Shortcomings -that it does not take into consideration
a person's change in moral character
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ETHICS TOOLS
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The Rings of Uncertainty

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Step One
• The traditional aim of health work is to move from the
outside to the inside – to come ever closer to certainty.
• It is sometimes better that a doctor moves outwards in
the Rings – especially if she thinks of herself as a general
problem-solver who wants to work for health

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Step Two: the

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Rings expressed

• Technical
competence

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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• Resources

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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• Law

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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• Communication

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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• Ethics

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Step Three

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Step Four

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Step Five
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A key dictum
• It is possible to derive a key dictum from this that if a
health worker’s imagination shows him standing
outside the Rings for any segment then this is a very
strong indication that a limit to health work has been
reached. Unless the circumstances are exceptional, the
worker should not proceed.
• What if the health worker has divided his/her Rings of
Uncertainty into four segments and conceives of
himself/herself as standing in the centre for two and at
the edges of the outer ring for the other two segments?
How is he/she to assess his/her most appropriate role in
these circumstances?
Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Step Six

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Scoring and quantification

• The Rings of Uncertainty are designed primarily as conceptual
guidelines, not to provide rigid, quantifiable rulings
• As one means of orientation a doctor might decide to score the
centre of the Rings as 4, the next ring as 3, the outer ring as 2,
and the surrounding area as 0.
• He/She might decide he/she will add up the scores for each
ring, divide by the number of segments, and accept a cut-off
point of say, less than 3, as a guide that he/she should not
proceed.
• If he/she chooses a lower cut-off point, then he/she will be
choosing to take greater risks, but may find other benefits
along the way.
Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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The IFS Model

• The IFS model is a visual tool to help analyse the
consequences of an action on various levels and areas

An act is defined as an interaction between two individuals. The interaction

may be so subtle that neither individual is aware of any action. This would for
instance include unconscious interactions such as the transference and counter
transference between patient and doctor.

Dr. Ben Greene. Medical ethics. http://www.priory.com/printer_friendly.php#seedhouse [ Accessed

24 May, 2020]
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Effects may ripple outwards from the interaction.

Dr. Ben Greene. Medical ethics. http://www.priory.com/printer_friendly.php#seedhouse [ Accessed

24 May, 2020]
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The Ethical Grid

Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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The Hippocratic Oath in perspective: “ The

6 keys to ethical orthodontics”?

Hippocrates, a Greek physician, was born about 460 BCE.

The Hippocratic Corpus is a collection of medical texts
attributed to Hippocrates, although it is not known
whether he wrote the entire document himself or whether
his followers wrote it after his death. One well-known
article in the corpus is the Hippocratic Oath.

Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical orthodontics”?. American Journal
of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
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I swear by Apollo . . . to keep according to my ability

and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught

me this art; to live in common with him and, if
necessary, to share my goods with him; To look upon
his children as my own brothers, to teach them this art;
and that by my teaching, I will impart a knowledge of
this art to my own sons, and to my teacher's sons . . .

1. Respect the educators and senior practitioners

(gratitude). Respect senior practitioners and be
especially grateful to those who taught you the art and
science of orthodontics.
Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical orthodontics”?. American Journal
of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
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I will prescribe regimens for the good of my patients

according to my ability and my judgment and never do
harm to anyone.

Do good (beneficence). Act in the patient’s best interest.

Always explain your treatment plan thoroughly.
Remember that you are not just treating a malocclusion;
most importantly, you are treating a person.

Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical orthodontics”?. American Journal
of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
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I will give no deadly medicine to any one if asked, nor

suggest any such counsel; and similarly I will not give a
woman a pessary to cause an abortion.

But I will preserve the purity of my life and my arts.

Do no harm (nonmaleficence). Be aware of your own

potential. Avoid procedures that might harm your patients.
Do no harm (nonmaleficence). Be aware of your own
potential. Avoid procedures that might harm your patients.

Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical orthodontics”?. American Journal
of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
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I will not cut for stone, even for patients in whom the
disease is manifest; I will leave this operation to be
performed by practitioners, specialists in this art.

Self-awareness (beneficence and veracity). Never hesitate

to refer a patient when necessary. Complicated clinical
problems might be best treated in a university or a hospital
setting. Don’t be afraid to say “I don’t know.” It is an
honest statement.
Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical orthodontics”?. American Journal
of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
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In every house where I come I will enter only for the good
of my patients, keeping myself far from all intentional ill-
doing and all seduction and especially from the pleasures
of love with women or with boys, be they free or slaves.

Professionalism. Avoid becoming personally involved with

your patients. Respect their vulnerability. The orthodontist
is responsible for establishing a “neutral safe zone” where
patients can benefit the most.
Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical orthodontics”?. American Journal
of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
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What I may see or hear in the course of the treatment . . .

in regards to the life of men . . . I will keep to myself
holding such things shameful to be spoken about.

Confidentiality (fidelity). Do not disclose any private

information, either deliberately or accidentally.

Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical orthodontics”?. American Journal
of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
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If I keep this oath faithfully, may I enjoy my life and

practice my art, respected by all humanity and in all
times; but if I swerve from it or violate it, may the reverse
be my life.

Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical orthodontics”?. American Journal
of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
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The Declaration of Geneva (1948, revised 1968 and 1983)

“At the time of being admitted as a Member of my Profession:

I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity;
The health of those in my care will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour and the noble traditions of
my profession;
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability, creed, ethnic origin,
gender, nationality, political affiliation, race, sexual orientation, or social standing to
intervene between my duty and my patient;
I will maintain the utmost respect for human life from its beginning, even under
threat, and I will not use my specialist knowledge contrary to the laws of humanity;
I make these promises solemnly, freely, and upon my honour.”
Hurwitz B, Richardson R. Swearing to care: the resurgence in medical oaths. BMj. 1997 Dec 20;315(7123):1671-
4.
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The Revised Declaration of Geneva A

Modern-Day Physician’s Pledge

• A newly revised version of the Declaration of Geneva was

adopted by the World Medical Association (WMA)
General Assembly on October 14, 2017, in Chicago

Parsa-Parsi RW. The revised declaration of Geneva: a modern-day physician’s pledge. Jama. 2017 Nov
28;318(20):1971-2.
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AS A MEMBER OF THE MEDICAL PROFESSION:

I SOLEMNLY PLEDGE to dedicate my life to the service of
humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be
my first consideration;
I WILL RESPECT the autonomy and dignity Of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or
disability, creed, ethnic origin, gender, nationality, political
affiliation, race, sexual orientation, social standing, or any
other factor to intervene between my duty and my patient;
I WILL RESPECT the secrets that are confided in me, even
after the patient has died;

Parsa-Parsi RW. The revised declaration of Geneva: a modern-day physician’s pledge. Jama. 2017 Nov
28;318(20):1971-2.
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I WILL PRACTICE my profession with conscience and
dignity and in accordance with good
medical practice;
I WILL FOSTER the honour and noble traditions of the
medical profession;
I WILL GIVE to my teachers, colleagues, and students the
respect and gratitude that is their due;
I WILL SHARE my medical knowledge for the benefit of
the patient and the advancement of healthcare;
I WILL ATTEND TO my own health, well-being, and
abilities in order to provide care of the highest standard;
I WILL NOT USE my medical knowledge to violate human
rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely, and upon my
honour.
Parsa-Parsi RW. The revised declaration of Geneva: a modern-day physician’s pledge. Jama. 2017 Nov
28;318(20):1971-2.
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A clause has been inserted into the 2017 version which says,
“I will respect the autonomy and dignity of my patient”.

A somewhat unusual new clause requires doctors to look

after their own health: “I will attend to my own health, well-
being, and abilities in order to provide care of the highest
standard”.

There is a new obligation on physicians to share their

knowledge for the benefit of their patients and for the
advancement of healthcare.
Michael Cook. New Hippocratic Oath for doctors approved. https://
www.bioedge.org/bioethics/new-hippocratic-oath-for-doctors-approved/12496 [Accessed 24th May, 2020]
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1948: I will maintain the utmost respect for human life from
the time of conception  
2017: I will maintain the utmost respect for human life.

1948: even under threat, I will not use my medical

knowledge contrary to the laws of humanity  
2017: I will not use my medical knowledge to violate human
rights and civil liberties, even under threat.

1948: I will maintain by all the means in my power, the

honor and the noble traditions of the medical profession; my
colleagues will be my brothers 
2017: I will foster the honour and noble traditions of the
medical profession
Michael Cook. New Hippocratic Oath for doctors approved. https://
www.bioedge.org/bioethics/new-hippocratic-oath-for-doctors-approved/12496 [Accessed 24th May, 2020]
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ETHICAL ISSUES
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ETHICAL ISSUES OF . . .
Abuse of prescriptions by patients

• The dentist must be aware of patients’ legitimate needs for

prescription drugs.
• The dentist should be suspicious when patients’ desires for
prescription drugs materially conflict with professional
recommendations.
• The dentist should confront patients when non-confrontation
would imply tacit approval of drug abuse.
• In a case of suspected drug abuse, the dentist has a responsibility
to refer the patient for evaluation.
• The dentist has an ethical obligation to avoid becoming an enabler.
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Access to dental care

• Care should be available, within reason, to all seeking treatment.
Once an individual is seen, the dentist can determine if he or she
is capable of competently treating the individual.
• A dentist should normally be available to address potentially
health-threatening dental conditions and to ease pain and
suffering.
• A dentist must not unlawfully restrict access to professional
services. Barriers that restrict the access of physically impaired
individuals should be eliminated to the extent that this can be
reasonably accomplished.
• Dentists must be aware of laws and regulations that govern
discrimination and access to care.
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Advertising
Advertising by a dentist must not:
1. Misrepresent fact;
2. Mislead or deceive by partial disclosure of relative facts;
3. Create false or unjustified expectations of favorable results;
4. Imply unusual circumstances;
5. Misrepresent fees;
6. Imply or guarantee atypical results;
7. Represent or imply a unique or general superiority over
other practitioners regarding the quality of dental services
when the public does not have the ability to reasonably verify
such claims.
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Child abuse
• Dentists are positioned to detect certain acts of child abuse,
particularly to the perioral area. Cases of child abuse must be
reported to the appropriate authorities.
• Suspicious incidents require documentation and careful
investigation.
• A dentist may need to compromise patient confidentiality by
conferring with authorities or medical personnel as a part of
an investigation.
• The dentist must be cautious when drawing conclusions or
making accusations, as an error in judgment may cause
irreparable harm to the reputation and quality of life of those
involved.
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Competence and judgement

As G.V. Black said, “Every professional person has no right
to be other than a continuous student.”

Dentists should maintain basic levels of competency and

restrict patient care to areas in which they are competent.
Dentists, therefore, must know the boundaries of their
competence, including their abilities and limitations.

Maintaining competence requires a commitment to

lifelong learning.
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Confidentiality
• The accepted standard is that every fact revealed to the dentist by a
patient is, in principle, subject to the requirement of
confidentiality, so that nothing may be revealed to anyone else
without the patient’s permission.
Exceptions:
• It is assumed that other health professionals may be told the facts
they need to know about a patient to provide effective care.
• It is also assumed that relevant ancillary personnel, such as record
keepers, will need to know some of the facts revealed to them by
the dentist to perform their job.
• Further, relevant facts may be communicated to students and other
appropriate health care professionals for educational purposes.
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• If maintaining confidentiality places others at risk, then

the obligation to breach confidentiality increases
according to the severity of the risk and the probability
of its occurrence.

• For some infectious diseases there may be no community

standard regarding the dentist’s obligation to protect
patient confidentiality when third parties are at risk of
infection
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Dating patients
• Dentists should not use their position of influence to
solicit or develop romantic relationships with patients.
• In such a case, the dentist should consider terminating
the dentist patient relationship in an arrangement
mutually agreeable to the patient.
• Dentists should avoid creating perceptions of
inappropriate behavior.
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Delegation of duties
• In the course of patient care, duties are often
appropriately delegated to auxiliaries
• Two important questions should be asked:
1. Does the use of the auxiliary for the delegated task
comply with prevailing laws and regulations?
2. Is the quality of care to patients maintained when duties
are delegated to auxiliaries?
• If the answers to both questions are “yes,” then the
delegation of duties may be considered.
• Duties should not be delegated at the expense of quality.
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Digital communication and social media

8 principles apply:
• The professional relationship between dentist and patient
should not be compromised by the use of digital
communication;
• Digital communication should not permit third parties to
influence the dentist-patient relationship;
• Dentists should exercise prudence to ensure that messages
are professional and cannot be used in unprofessional ways
by others;
• Personal data should be protected and professional
communication should be separated from personal
communication;
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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• Dentists should be generally familiar with the potential

of digital communication, applicable laws, and the types
of information patients have access to on the Web;
• Practitioners should maintain an appropriate distinction
between communication that constitutes the practice of
dentistry and other practice-related communication;
• Responses to criticism on digital media should be
managed in a professional manner;
• Dentists should be prepared to make more
accommodations to patients than patients do to dentists
in College
American resolving misunderstandings
of Dentists. Ethics about
handbook for dentists, an introduction treatment.
to ethics, professionalism, and ethical
decision making
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Disclosure and misrepresentation

• The dentist has an obligation to represent professional
qualifications accurately without overstatement of fact or
implying credentials that do not exist.
• A dentist has an obligation to avoid shaping the
conclusions or perceptions of patients or other
professionals by withholding or altering information that
is needed for accurate assessment.
• The dentist has an obligation to disclose commercial
relationships with companies when recommending
products of those companies
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Emergency care
• A dentist should be available, within reason, to address
acute dental conditions.
• A person with an emergent dental condition should be
examined and either treated or referred for treatment.
• In such situations, the patient’s health and comfort must
be the dentist’s primary concern, not compensation or
convenience.
• If a dentist cannot accommodate the patient’s emergent
needs, a reasonable effort should be made to have the
patient seen in a timely manner by someone capable of
treating the condition.
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Financial arrangements
• The issue of financial arrangements includes fees and
communication of payment options. Fees should be
consistent and fair to all parties.
• Many dentists provide pro bono care for patients with
extenuating circumstances.
• Dentists should not vary fees based solely on the
patient’s financial resources or insurance plan.
• In non-emergency situations fees and payment options
should be disclosed to patients and agreed upon prior to
any services being performed.
• Financial arrangements for treatment are part of
informed consent/refusal discussions
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Harassment
• The dentist must avoid conditions or actions that
promote harassment or abuse of staff, patients, or other
related parties.
• Sexual harassment may be the most familiar form, but
harassment may also be physical, verbal, or
psychological in nature.
• Sexual advances, sexually explicit or offensive language,
sexually offensive materials, inappropriate physical
contact, and actions of a related nature are indefensible
and must be avoided.
• The dentist must be aware of signs of harassment and
must strive to eliminate it from the workplace
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Obligation to treat patients

• The dentist is not obligated to diagnose or treat
everyone.
• However, the dentist must avoid actions that could be
interpreted as discriminatory; the dentist must be aware
of laws and regulations that govern discrimination.
• A patient in pain or at health risk from an acute dental
condition should be accepted for discussion of the
condition, examined if indicated, then either treated or
appropriately referred
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Refraining from treatment

Several valid reasons
1. The dentist does not have the expertise or capability to
provide competent treatment or to meet patient expectations.
In such cases, the dentist has a responsibility to refer patients
to suitable caregivers who can provide treatment appropriate to
the circumstances;

2. The dentist’s professional ability is impaired from injury,

illness, disability, medication, or addiction;

3. The patient requests treatment that is clearly contrary to the

patient’s best interests.
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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PATIENTS WITH DISABILITIES OR

BLOODBORNE PATHOGENS
As is the case with all patients, when considering the
treatment of patients with a physical, intellectual or
developmental disability or disabilities, including patients
infected with Human Immunodeficiency Virus, Hepatitis B
Virus, Hepatitis C Virus or another bloodborne pathogen,
or are otherwise medically compromised, the individual
dentist should determine if he or she has the need of
another’s skills, knowledge, equipment or expertise, and if
so, consultation or referral pursuant to another expert is
indicated.
American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official
advisory opinions revised to November 2018.
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Decisions regarding the type of dental treatment provided,

or referrals made or suggested, should be made on the
same basis as they are made with other patients.

The dentist should also determine, after consultation with

the patient’s physician, if appropriate, if the patient’s
health status would be significantly compromised by the
provision of dental treatment.

American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official
advisory opinions revised to November 2018.
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Medical oaths, declarations, and codes

The Declaration of Geneva (1948, revised 1968 and
1983) is a sort of updated version of the Hippocratic Oath.

The World Medical Association's international

code of medical ethics, adopted in London in 1949
and revised in 1968 and 1983, requires, among other
things, adherence to the Declaration of Geneva, the highest
professional standards, clinical decisions uninfluenced by
the profit motive, honesty with patients and colleagues,
and exposure of incompetent and immoral colleagues
Gillon R. Medical oaths, declarations, and codes. British medical journal (Clinical research ed.). 1985 Apr
20;290(6476):1194.
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The Declaration of Helsinki (1964, revised 1975

and 1983) governs biomedical research in human
subjects, and among its many principles is the stipulation
that "the interests of the subject must always prevail over
the interests of science and society."' It also requires that
in any research the doctor should "obtain the subject's
freely given informed consent."

Gillon R. Medical oaths, declarations, and codes. British medical journal (Clinical research ed.). 1985 Apr
20;290(6476):1194.
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The Declaration of Lisbon (1981) concerns the rights

of the patient. These are declared to include the rights to
choose his or her physician freely; to be cared for by a
doctor whose clinical and ethical judgments are free from
outside interference; to accept or refuse treatment after
receiving adequate information; to have his or her
confidences respected; to die in dignity; and to receive or
decline spiritual and moral comfort including the help of a
minister of an appropriate religion.'

Gillon R. Medical oaths, declarations, and codes. British medical journal (Clinical research ed.). 1985 Apr
20;290(6476):1194.
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The Declaration of Sydney (1968, revised 1983), on

death, states among other things that "clinical interest lies
not in the state of preservation of isolated cells but in the
fate of a person" and it stipulates the much more specific
rule that when transplantation of a dead person's organs is
envisaged determination of death should be by two doctors
unconnected with the transplantation.

Gillon R. Medical oaths, declarations, and codes. British medical journal (Clinical research ed.). 1985 Apr
20;290(6476):1194.
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The Declaration of Oslo (1970, revised 1983), on

abortion, remains, even after its recent revision, which
changed "human life from conception" to "human life from
its beginning," the most equivocal of all these declarations
for it requires doctors both to maintain the utmost respect
for human life from its beginning and to accept that
attitudes towards the life of the unborn child are diverse
and "a matter of individual conviction and conscience
which must be respected." Subject to a host of
qualifications the declaration has always sanctioned
therapeutic abortion.

Gillon R. Medical oaths, declarations, and codes. British medical journal (Clinical research ed.). 1985 Apr
20;290(6476):1194.
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The Declaration of Tokyo (1975, revised 1983), on

torture, is unequivocal in forbidding doctors to
"countenance, condone, or participate in the practice of
torture or other forms of cruel, inhuman, or degrading
procedures."' It also forbids force feeding of mentally
competent hunger strikers.

Gillon R. Medical oaths, declarations, and codes. British medical journal (Clinical research ed.). 1985 Apr
20;290(6476):1194.
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The Declaration of Hawaii (1977, revised 1983), on

psychiatric ethics, requires inter alia: that patients be
offered the best treatment available and be given a choice
when there is more than one appropriate treatment; that
compulsory treatment be given only if the patient lacks the
capacity to express his wishes, or, owing to psychiatric
illness, cannot see what is in his best interests or is a
severe threat to others; that there must be an independent
and neutral appeal body for those treated compulsorily

Gillon R. Medical oaths, declarations, and codes. British medical journal (Clinical research ed.). 1985 Apr
20;290(6476):1194.
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Nuremberg Code, 1947

• underlines the indispensability of the respect of the
integrity and the dignity of individuals, and ratifies on
one side the priority of a voluntary consensus of the
patients and of the individuals under experimental
protocols, while on the other side the sense of ethical
responsibility, professionality and legality required of the
doctor whenever an experimental research would result
harmful to the individual.
• The “voluntary consensus” becomes an “essential”
prerequisite for a morally acceptable conduct of the
experiments on humans.
Marinozzi S, Corbellini G, Ottolenghi L, Ripari F, Pizzuti A, Pezzetti M, Gaj F. From Nuremberg to bioethics: an educational
project for students of dentistry and dental prosthesis. Annali di stomatologia. 2013 Jan;4(1):138.
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CONSENT
The granting of permission by the patient for another
person to perform an act e.g. permission for a surgical or
therapeutic procedure or experiment to be performed by a
physician, dentist, nurse or other health care professional
is Consent.

Srivastava CP. Consent. Journal of Universal College of Medical Sciences. 2013;1(4):69-70.

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TYPES OF CONSENT
1. Implied consent – which is not written as happens
in OPD
2. Express consent – anything other than implied
consent is express consent. It may be oral or written.
• oral consent is for minor examinations or therapeutic
procedures
• written consent is obtained for all the major diagnostic
procedures, general anaesthesia, or surgical procedures
or operation
3. Informed consent – is in writing and distinct

Srivastava CP. Consent. Journal of Universal College of Medical Sciences. 2013;1(4):69-70.

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Informed consent: Paternalism Versus

Autonomy
• The clinician’s goal should be to bridge the gap between
the professional’s point of view and the patient’s, thereby
achieving a mutual understanding and consensus.

• This can be achieved only through an orthodontist –

patient or – parent dialogue, the aim of which is to
jointly construct treatment goals that satisfy both the
doctor and the patient

Ackerman JL, Proffit WR. Communication in orthodontic treatment planning: bioethical and informed consent issues.
The Angle Orthodontist. 1995 Aug;65(4):253-62.
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It is now doctor’s legal as well as moral responsibility to

advise a patient of the risk/ benefit considerations of a
contemplated treatment and to discuss alternative
treatment possibilities. Possible compromise treatment
should be included in the list of treatment alternative, and
the doctor is also obliged to explain the risk associated
with no treatment at all. This obligation to properly inform
patients and gain their consent is known as the doctrine
of informed consent.

Ackerman JL, Proffit WR. Communication in orthodontic treatment planning: bioethical and informed consent issues.
The Angle Orthodontist. 1995 Aug;65(4):253-62.
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• Not so long ago, it was taken for granted that the doctor
should analyze the patient’s situation and should
prescribe what he or she determined to be the best
treatment—with little or no regard for whether that
treatment was what the patient desired.
• This is best described as a paternalistic approach to
patient care: the doctor, as a father figure, knows best
and makes the decisions.
• At present, this approach is not defensible, ethically or
legally.
Proffit WR, Fields HW, Larson B, Sarver DM. Contemporary orthodontics-e-book. Elsevier Health Sciences; 2018 Aug 6.
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In discussing treatment alternatives with parents and

patients, the orthodontist must deal with three competing
values:
1. The wish to be clear, concise and direct
2. The desire to be kind and not to overly alarm the
parents and patients
3. The hope that they will accept treatment

Ackerman JL, Proffit WR. Communication in orthodontic treatment planning: bioethical and informed consent issues.
The Angle Orthodontist. 1995 Aug;65(4):253-62.
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• First frequent problem

arch expansion versus extraction in solving crowding
problems
• Second frequent problem
whether to begin treatment for a skeletal problem before
adolescence or wait until the adolescent growth spurt
• Third frequent problem
whether orthodontic treatment alone would produce an
acceptable result, or whether orthognathic surgery should
be selected
Proffit WR, Fields HW, Larson B, Sarver DM. Contemporary orthodontics-e-book. Elsevier Health Sciences; 2018 Aug 6.
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It is not the doctor’s responsibility to do anything the

patient wants. Just as any patient has the right to refuse to
accept treatment, the doctor has the right to refuse to carry
out treatment that he or she considers not in the patient’s
best interest.

Proffit WR, Fields HW, Larson B, Sarver DM. Contemporary orthodontics-e-book. Elsevier Health Sciences; 2018 Aug 6.
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From Whom Consent is obtained:

1. Conscious, mentally sound adults normally give consent
themselves.
2. Adolescent between age above 12 years but below 18 years can
give consent for medical examination but not informed consent
about procedure/operation.
3. If less than 10 years informed consent from parents.
4. If the patient is not conscious or mentally sound, guardian next
to kin can give consent on behalf of the patient.
5. In any procedure affecting the rights of spouse, e.g. sterilization,
hysterectomy, artificial insemination informed consent from
spouse is necessary.
6. The consent given may be invalid if the act consented is unlawful
i.e.criminal abortion.
Srivastava CP. Consent. Journal of Universal College of Medical Sciences. 2013;1(4):69-70.
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The ACD Test For Ethical Decisions

Assess
• Is it true?
• Is it accurate?
• Is it fair?
• Is it quality?
• Is it legal?
Communicate
• Have you listened?
• Have you informed the patient?
• Have you explained outcomes?
• Have you presented alternatives?
Decide
• Is now the best time?
• Is it within your ability?
• Is it in the best interests of the patient?
• Is it what you would want for yourself?
American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and ethical
decision making
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MEDICAL NEGLIGENCE
An act or omission (failure to act) by a medical professional
that deviates from the accepted medical standard of care.
Negligence are of two types;
1. Civil negligence where the doctors are alleged to
have lost simple degree of care and attention to the
patients thereby causing damage
2. Criminal negligence, where the doctors grossly
deviate from the standard of care and competence or
perform activities which are understood prima facie as
a crime, for eg: performing criminal abortion, organ
transplantation against the law etc
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According to Bolam’s test, a person is said to have

inappropriate standard, and becomes negligent, if it is
proven that he had failed to do what a reasonable person
would do in the circumstances
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PENAL CODE: CHAPTER 19: Offence Relating

to Medical Treatment
230. Prohibition of conducting medical treatment by
person who has not obtained licence

• liable to a sentence of imprisonment for a term not

exceeding three years and a fine not exceeding thirty
thousand rupees.
• offender shall be liable to the sentence of imprisonment
for life where any act of providing medical service,
conducting surgery or administering drug in contravention of
subsection (1) causes the death of any person, and to a
sentence of imprisonment for a term not exceeding fifteen
years where such act causes grievous hurt.
National Penal (Code) Act, 2017 http://
www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf [Accessed 27th
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231. Prohibition of conducting medical

treatment maliciously
• liable to the following sentence:

(A) The same sentence as imposable for murder,

in the case of causing the death of any person,
(B) The same sentence as imposable for grievous
hurt, in the case of causing grievous heart to any
person

National Penal (Code) Act, 2017 http://

www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf [Accessed 27th
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232. Prohibition of conducting medical

treatment by recklessness or negligence

• the offender shall be liable to a sentence of

imprisonment for a term not exceeding five years and a
fine not exceeding fifty thousand rupees if the death or
grievous hurt has been caused from a reckless act and
to a sentence of imprisonment for a term not exceeding
three years and a fine not exceeding thirty thousand
rupees if the death or grievous hurt has been caused
from a negligent act.
National Penal (Code) Act, 2017 http://
www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf [Accessed 27th
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233. Prohibition of carrying out experiment

on human body without consent
• liable to a sentence of imprisonment for a term not
exceeding three years and a fine not exceeding thirty
thousand rupees.

• liable to the same sentence as imposable for murder if

the offence referred to in sub-section (1), (2) or (3)
causes the death of any one and to the same sentence as
imposable for grievous hurt if such offence causes
grievous hurt to any one.

National Penal (Code) Act, 2017 http://

www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf [Accessed 27th
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234. Prohibition of selling dangerous drug

• liable to a sentence of imprisonment for a term
not exceeding two years or a fine not exceeding
twenty thousand rupees or both the sentences.

National Penal (Code) Act, 2017 http://

www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf [Accessed 27th
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235. Prohibition of adulteration of drugs or

sale of adulterated drugs
• The same sentence as imposable for murder, in the case
of death
• The same sentence as imposable for attempted murder,
in the case of danger or likelihood of danger to cause
death
• A sentence of imprisonment for a term not exceeding ten
years and a fine not exceeding one hundred thousand
rupees, in the case of any grievous hurt or deterioration
• A sentence of imprisonment for a term not exceeding
five years and a fine not exceeding fifty thousand rupees
inNational
cases other than that referred to in clause
Penal (Code) Act, 2017 http://
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236. Prohibition of selling, distributing date-

expired drugs or without taking precaution
• liable to a sentence of imprisonment for a term not
exceeding one year and a fine not exceeding ten
thousand rupees

National Penal (Code) Act, 2017 http://

www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf [Accessed 27th
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237. Prohibition of selling, distributing of

drug as a different drug
• liable to a sentence of imprisonment for a term
not exceeding two years or a fine not exceeding
twenty thousand rupees or both the sentences.

National Penal (Code) Act, 2017 http://

www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf [Accessed 27th
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238. Prohibition of giving false report

• liable to a sentence of imprisonment for a term not exceeding three
years and a fine not exceeding thirty thousand rupees.

• Where the consumption of any drug prescribed to, conduction of a

surgery on, or treatment of, a person on the basis of the report
referred to in sub-section (1) causes the death of or any grievous
hurt to such person, the person giving such report shall be deemed
to be the offender.

• liable to the same sentence as imposable for murder, in the case of

causing death of, and to the same sentence as imposable for
grievous hurt, in the case of causing grievous heart to, any person
National Penal (Code) Act, 2017 http://
www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf [Accessed 27th
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239. Compensation to be paid

reasonable compensation shall be ordered to be
paid by the offender to the concerned victim and
to his or her successor if the victim is dead.

National Penal (Code) Act, 2017 http://

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Duties of medical practitioners

to colleagues
A Medical practitioner SHALL
Behave towards colleagues as he/she would have them
behave towards him/her.
NOT undermine the patient-medical practitioner
relationship of colleagues in order to attract patients.
When medically necessary, communicate with colleagues
who are involved in the care of the same patient. This
communication should respect patient confidentiality
and be confined to necessary information.

Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
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Few examples of violation of code which

are punishable:

Failure to assess mental soundness/capacity and take

informed consent
Failure to treat in an emergency
Failure to maintain medical records
Breach of confidentiality
Terminating doctor-patience relationship unjustly
Disparagement of other medical practitioners
Obtaining personal gains from improper financial
transactions with pharmaceutical or medical equipment
companies
Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
 134

Few examples of violation of code UCMS - CODS

which are punishable:

Failure of proper communication with patient
Abuse of alcohol or drug while on duty
Extracting excess fees from patients
Working with unqualified or unauthorized person
Taking commission while referring patient, investigation and
while prescribing drugs and equipment
Treating a patient in private clinics or nursing homes by
medical practitioner during duty hours away from primarily
employed hospitals.
Medical practitioners pursuing higher education and
simultaneously practicing in other places away from her/his
studying institution

Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
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Few examples of violation of code which

are punishable:
Practicing medicine without fitness to practice
Practicing beyond level of competency
Improper personal relationship with patient, patient’s family
members or relatives and juniors misusing her/his dominant status
Disseminating misleading information to public
Irrational drug prescription
Practicing complementary and alternative medicine without being
qualified
Issuing false certificate
Exerting undue pressure or creating situation to compel a patient
admitted at government hospital to visit private clinic or nursing
home.

Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
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Why are orthodontic records important?

STUDY MODELS
• an invaluable aid in the defence of any litigation that
may arise in the future.
• Neither the clinician nor the patient can reliably recall
the original status of the dentition two or more years
later.

Mizrahi E. Risk management in clinical practice. Part 7. Dento-legal aspects of orthodontic practice. British dental
journal. 2010 Oct;209(8):381.
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Why are orthodontic records important?

Photographs
• contributing to the record component required in any
litigation situation that may arise.
• Not only do photographs provide a record of the
malocclusion, they also provide a good record of colour
blemishes, mottling, decalcification and staining, all
issues that could be a source of future litigation.

Mizrahi E. Risk management in clinical practice. Part 7. Dento-legal aspects of orthodontic practice. British dental
journal. 2010 Oct;209(8):381.
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Why are orthodontic records important?

Radiographs
• Having a radiographic record of the near final position of
the teeth, jaw relationships, bone condition and soft
tissue drape does give the clinician some degree of
protection with regard to possible future legal claims
that may be instituted by the patient.

Mizrahi E. Risk management in clinical practice. Part 7. Dento-legal aspects of orthodontic practice. British dental
journal. 2010 Oct;209(8):381.
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Ethical practice during the COVID-19

pandemic
The ADA Code directs dentists to “have the benefit of the patient
as their primary goal.” This might cause you to wonder how you
can ethically defer elective procedures or even temporarily
suspend your practice operations.

By deferring or suspending procedures, we are protecting our

patients and our communities from the coronavirus that causes
COVID-19. Such measures allow us to, for example, reduce the
aerosol in the office that is produced by high-speed handpieces,
ultrasonic scaling units, and prophylaxis cups. This is precisely
what Section 2, the principle Nonmaleficence, demands of us
in imposing the “duty to refrain from harming the patient.”
Cohen DF, Kurkowski MA, Wilson RJ, Jonke GJ, Patel OR, Pappas RP, Hall DW, Pandya A. Ethical practice during the
COVID-19 pandemic. The Journal of the American Dental Association. 2020 May 1;151(5):377-8.
 140

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Cohen DF, Kurkowski MA, Wilson RJ, Jonke GJ, Patel OR, Pappas RP, Hall DW,
Pandya A. Ethical practice during the COVID-19 pandemic. The Journal of the
American Dental Association. 2020 May 1;151(5):377-8.

We also are engaging in social distancing by reducing the

close contact between other patients as well as staff
members, thus limiting the risk of harm to patients, staff
members, and ourselves. All of these efforts help “flatten
the curve.”
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Cohen DF, Kurkowski MA, Wilson RJ, Jonke GJ, Patel OR, Pappas RP,
Hall DW, Pandya A. Ethical practice during the COVID-19 pandemic.
The Journal of the American Dental Association. 2020 May
1;151(5):377-8.

We also are conserving personal protective equipment

(PPE) that can be used for patients with urgent needs.
Such measures are supported by Section 3, the principle
Beneficence, which is about promoting the patient’s
welfare

If you run out of PPE, you have an obligation to not

continue business as usual.
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Cohen DF, Kurkowski MA, Wilson RJ, Jonke GJ, Patel OR, Pappas RP,
Hall DW, Pandya A. Ethical practice during the COVID-19 pandemic.
The Journal of the American Dental Association. 2020 May
1;151(5):377-8.
• Limiting practice, however, does raise some concerns
about the principle of Justice that bear consideration
under these unusual circumstances.
• Although you may need to limit or even close your
practice temporarily, it is not appropriate to send
patients of record to the local emergency department,
public health clinic, or dental school for treatment, as
these settings may be overburdened already with direct
disease response. Nonetheless, you should work with
your colleagues to ensure that you are all able to “make
reasonable arrangements for the emergency care of ...
patients of record.”
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Cohen DF, Kurkowski MA, Wilson RJ, Jonke GJ, Patel OR, Pappas RP,
Hall DW, Pandya A. Ethical practice during the COVID-19 pandemic.
The Journal of the American Dental Association. 2020 May
1;151(5):377-8.
• Shutting down, even temporarily, is a cause for concern not
just for patients but for dentists and their livelihoods, as well
as those of their staff members. Out of financial concern,
some have expressed their intention to continue their day-to-
day practice.
• However, when money drives the decision process, ethics
often will be compromised.
• The compelling ethical obligation to “act for the benefit of
others” (the principle of Beneficence) should be the priority,
which may mean temporarily limiting service.
• We are all at risk, and we must all act with concern for one
another to mitigate the damage in the most humane way
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Cohen DF, Kurkowski MA, Wilson RJ, Jonke GJ, Patel OR, Pappas RP,
Hall DW, Pandya A. Ethical practice during the COVID-19 pandemic.
The Journal of the American Dental Association. 2020 May
1;151(5):377-8.

During this challenging time, we are in the position of

balancing the interests of patients, office staff members,
and the entire community. To promote the greatest good
for the greatest number, providing limited services to only
those with urgent needs is supported by the principle of
Beneficence. This is a time to unite as a community and
as a profession to do what is needed in the best interest of
society.
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References
• American College of Dentists. Ethics handbook for dentists, an introduction to ethics, professionalism, and
ethical decision making.
• Proffit WR, Fields HW, Larson B, Sarver DM. Contemporary orthodontics-e-book. Elsevier Health
Sciences; 2018 Aug 6.
• Lawrence DJ. The four principles of biomedical ethics: a foundation for current bioethical debate. Journal
of Chiropractic Humanities. 2007 Jan 1;14:34-40.
• Ackerman JL, Proffit WR. Communication in orthodontic treatment planning: bioethical and informed
consent issues. The Angle Orthodontist. 1995 Aug;65(4):253-62.
• Zogakis IP, Shalish M, Greco PM. The Hippocratic Oath in perspective:“The 6 keys to ethical
orthodontics”?. American Journal of Orthodontics and Dentofacial Orthopedics. 2013 Sep 1;144(3):324-5.
• American Dental Association. American Dental Association principles of ethics and code of professional
conduct, with official advisory opinions revised to November 2018.
• Nepal Medical Council. Code of Ethics & Professional Conducts. Fourth edition 2017.
• Jhunjhunwala S. Medical Negligence and Its Legal Aspect in Nepal. Available at SSRN 3243682. 2016 Jun
4.
• Cohen DF, Kurkowski MA, Wilson RJ, Jonke GJ, Patel OR, Pappas RP, Hall DW, Pandya A. Ethical practice
during the COVID-19 pandemic. The Journal of the American Dental Association. 2020 May 1;151(5):377-
8.
• Mizrahi E. Risk management in clinical practice. Part 7. Dento-legal aspects of orthodontic practice. British
dental journal. 2010 Oct;209(8):381.
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References
• National Penal (Code) Act, 2017
http://www.moljpa.gov.np/en/wp-content/uploads/2018/12/Penal-Code-English-Revised-1.pdf
[Accessed 27th May, 2020]
• Srivastava CP. Consent. Journal of Universal College of Medical Sciences. 2013;1(4):69-70.
• Marinozzi S, Corbellini G, Ottolenghi L, Ripari F, Pizzuti A, Pezzetti M, Gaj F. From Nuremberg to
bioethics: an educational project for students of dentistry and dental prosthesis. Annali di
stomatologia. 2013 Jan;4(1):138.
• Gillon R. Medical oaths, declarations, and codes. British medical journal (Clinical research ed.). 1985
Apr 20;290(6476):1194.
• Michael Cook. New Hippocratic Oath for doctors approved.
https://www.bioedge.org/bioethics/new-hippocratic-oath-for-doctors-approved/12496[Accessed
24th May, 2020]
• Parsa-Parsi RW. The revised declaration of Geneva: a modern-day physician’s pledge. Jama. 2017
Nov 28;318(20):1971-2.
• Hurwitz B, Richardson R. Swearing to care: the resurgence in medical oaths. BMj. 1997 Dec
20;315(7123):1671-4.
• Dr. Ben Greene. Medical ethics. http://www.priory.com/printer_friendly.php#seedhouse [ Accessed
24 May, 2020]
• Seedhouse D. Ethics: the heart of health care. John Wiley & Sons; 2008 Nov 20.
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