+
Ethics and Dental Public Health
+
Course Created By:
Kathryn Atchison, DDS, MPH
University of California, Los Angeles
+ This project is supported by the Health Resources and
Services Administration (HRSA) of the U.S. Department
of Health and Human Services (HHS) under grant
number D83HP19949 Predoctoral Training in General,
Pediatric, and Public Health Dentistry and Dental
Hygiene, grant amount $650,000. This information or
content and conclusions are those of the author and
should not be construed as the official position or
policy of, nor should any endorsements be inferred by
HRSA, HHS or the U.S. Government.
3
© AAPHD
+ Course Competency
Demonstrate the ability to incorporate
ethical reasoning and actions that promote
culturally competent oral health care to
individuals and populations.
4
© AAPHD
Course Objectives
+

Recognize the similarities and differences in the mission of
dental practitioners versus the dental public health
practitioner and how to respond to common ethical issues
facing each.

Describe the principles and values underlying dental public
health and compare to those for dental practitioners.

Demonstrate how the Code of Ethics developed for dental
practitioners will differ from that for the dental public health
practitioner.

Describe and apply a framework for analyzing the decisions
and actions to be made by dental public health
professionals.
© AAPHD
5
+
Lecture 1
Introduction to Ethics
6
© AAPHD
+
Lecture Objectives
 Recognize
the similarities and differences
in the mission of dental practitioners versus
the dental public health practitioner and
how to respond to common ethical issues
facing each.
 Describe
the principles and values
underlying dental public health and
compare to those for dental practitioners.
© AAPHD
7
+
What is Ethics?

The domain of understanding and action that relates
to an individual’s responsibility to others.

Those actions evaluated as right or wrong through
reasoned, objective criteria.

The values by which human beings live in relation to
other human beings.
© AAPHD
8
+
What is Public Health?
Institute of Medicine’s (1998) definition: “Public
health is what we, as a society, do collectively to
assure the conditions in which people can be
healthy.”
Each individual counts as only 1 of the community.
© AAPHD
9
+
Characteristics of a Profession

Specialized knowledge

Authority or power granted by society to the
profession

Self –regulations and a Code of Ethics

Professional Culture
© AAPHD
10
+
Overlapping and Separate
Concerns Affect DPH Ethics
Dental
Public
Health
Dentistry
© AAPHD
+
Mission for Dental Practitioner
vs. Dental Public Health
Practitioner
Dental Practitioner

Improving the health of the
patient

Providing individually
prescribed prevention and
treatment approaches to protect
and promote health; monitor the
patient’s health
Dental Public Health (DPH) Practitioner
 Improving the health of the community
through a combination of direct
preventive services and ways to
reduce social and health disparities
 Using a societal approach to protect
and promote health of the community
(e.g. programs such as school-based
sealant programs or fluoridation of
community water systems), monitor
health status and changes to health
status, advocate for laws/policies that
support health services
 Common approach: Health,
Community, Taking Action.
© AAPHD
12
Who is the DPH Practitioner and
What tools does a practitioner
use?
+

A DPH professional acts to improve the health of a
community.

What are the tools of a DPH professional that can
instigate an ethical dilemma?






Promotion of population health
Prevention of disease
Collection and use of epidemiologic data
Population surveillance
Recognition of multidimensional nature of determinants,
Focus on complex interactions of many factors (biologic,
behavioral, social, environmental
© AAPHD
13
+
Why values and beliefs?

Values: what we hold important

Beliefs: What we hold true

Values and beliefs underlie the ethical principles

Enable professionals to establish a sense of cohesiveness
with each other

Help to guide decision making
© AAPHD
14
+

What are Values?
The social principles,
goals or standards
held, or accepted by an
individual, profession,
or society

© AAPHD
A standard or criterion for
guiding
action
in
situations to justify one’s
own and other’s actions
and attitudes, for morally
judging self and others,
and for comparing self
with others (Sociologist)
15
Values and Beliefs for Public
Health Professionals
+
Health
1.
Humans have the right to resources necessary
for health.
Reference: Public Health Leadership Society, @2002
© AAPHD
16
+
Values and Beliefs for Public
Health Professionals
Community
2.
Humans are inherently social and
interdependent.
Ethical issues often may include a consideration of the individual’s
right to make a decision versus a decision on what is best for the
community.
Reference: Public Health Leadership Society, @2002
© AAPHD
17
Values and Beliefs for Public
Health Professionals
+
Community
3.
The effectiveness of institutions depends
heavily on the public’s trust.
Just as society grants a profession rights to govern, they expect certain
factors within the profession, truth telling, transparency, accountability,
reliability, and reciprocity.
Reference: Public Health Leadership Society, @2002
© AAPHD
18
+
Values and Beliefs for Public
Health Professionals
Community
4. Collaboration
is a key element for public
health.
A variety of dental and non-dental agencies and professional
organizations contribute to the dental public health mission.
Name a combination of 4 or more dental and non-dental agencies
and organizations and discuss how they work together to bring
dental health to the public. Discuss a recent example of such
collaboration.
Reference: Public Health Leadership Society, @2002
© AAPHD
19
Values and Beliefs for Public
Health Professionals
+
Community
5.
People and their environment are
interdependent.
People depend on the resources of their natural and constructed
environment. Search the web for standards for amalgam disposal
and discuss how this example represents good dental public health
practice.
Reference: Public Health Leadership Society, @2002
© AAPHD
20
+
Values and Beliefs for Public
Health Professionals
Community
6. Each
person in a community should have an
opportunity to contribute to public discourse.
In the process of creating dental policy, it is important for leaders
to provide opportunity to provide input through direct and/or
representative government means.
Reference: Public Health Leadership Society, @2002
© AAPHD
21
Values and Beliefs for Public
Health Professionals
+
Community
7.
Identifying and promoting the fundamental
requirements for health in a community are a
priority for public health.
Public health is concerned with the underlying structure of society
that can affect the health of the public. Since fundamental social
structures affect many aspects of health, addressing the
fundamental causes is truly preventive.
Reference: Public Health Leadership Society, @2002
© AAPHD
22
Values and Beliefs for Public
Health Professionals
+
Bases for Action
8.
Knowledge is important and powerful.
A profession has a specialized body of knowledge, and we seek to
improve our understanding of health and the means to protect it
through research and accumulation of knowledge.
Reference: Public Health Leadership Society, @2002
© AAPHD
23
Values and Beliefs for Public
Health Professionals
+
Bases of Action
9.
Science is the basis for much of our public
health knowledge.
Employing a full range of qualitative and quantitative scientific
methods in collaboration with other scientists is needed to identify
the factors necessary for health in the population.
Reference: Public Health Leadership Society, @2002
© AAPHD
24
Values and Beliefs for Public
Health Professionals
+
Bases of Action
10.
People are responsible to act on the basis of
what they know.
Having knowledge is not sufficient, one must act on the
knowledge. Give an example of where dental knowledge was
acted upon to improve the health of the US population.
Reference: Public Health Leadership Society, @2002
© AAPHD
25
Values and Beliefs for Public
Health Professionals
+
Bases of Action
11.
Action is not based on information alone.
In some instances, action is required before all information is
available. In others, policies are demanded based on the
fundamental value and dignity of human beings, even if
implementing such a policy is not optimally efficient or costeffective. In these instances, values inform the application of
information.
Reference: Public Health Leadership Society, @2002
© AAPHD
26
+
American Dental Association
 Principles
of Ethics: aspirational goals of the
profession that form the basis for justification for
the Code of Professional Conduct and the Advisory
Opinions.
 Code
of Professional Conduct:
a written
expression of specific types of conduct that are
required or prohibited for members of the ADA,
and adopted by the ADA’s House of Delegates.
 Advisory
Opinions: interpretations that apply the
Code of Professional Conduct to specific situations.
© AAPHD
27
Principles espoused by the
Dental Practitioner
+
Principles
1.
Patient Autonomy ("self-governance") : The dentist has a duty
to respect the patient's rights to self-determination and
confidentiality.
2.
Non-maleficence ("do no harm"): The dentist has a duty to
refrain from harming the patient.
3.
Beneficence ("do good") The dentist has a duty to promote
the patient's welfare.
4.
Justice ("fairness"): The dentist has a duty to treat people
fairly.
5.
Veracity ("truthfulness"):
communicate truthfully.
The
dentist
has
a
duty
to
Reference: ADA Code of Ethics: Principles, Code of Professional Conduct: & Advisory Opinions
© AAPHD
28
+
Patient Autonomy
Code of Professional Conduct:
1a. Patient Involvement: Dr should inform patient of
proposed treatment and reasonable alternatives, in a
manner that allows patient to be involved in
treatment decisions.
1b. Patient Records: Dr is obligated to safeguard the
confidentiality of patient records.
© AAPHD
29
+
Non-maleficience
Code of Professional Conduct:
2a. Education: The privilege of dentists to professional
status rests primarily in the knowledge, skill, and
experience with which they serve the patients and
society. Therefore, they must keep their knowledge
and skill current.
2b. Consultation and Referral: Dr are obligated to seek
consultation, if possible when the welfare of the
patient will be safeguarded or advanced.
© AAPHD
30
+
Beneficence
Code of Professional Conduct:
3a. Community Service: encouraged to be leaders in
the community and conduct themselves in a
manner to maintain or elevate the esteem of the
profession.
3b. Government of a Profession: Profession must
regulate itself, Dr. have dual obligation of making
themselves part of a professional society and
observe the rules of ethics.
© AAPHD
31
+
Beneficence
Code of Professional Conduct
3c. Research and Development
3d. Patents and Copyrights
3e. Abuse & Neglect: Dr. shall be obliged to become
familiar with the signs of abuse and neglect and to
report suspected cases to the proper authorities,
consistent with state laws.
© AAPHD
32
+
Justice
Code of Professional Conduct:
4a. Patient Selection: Dr. shall not refuse to accept
patients into their practice or deny service because of
the patient's race, creed, color, sex or national origin
4b. Emergency Service: Dr. is obliged to make
reasonable arrangements for the emergency care of
patients of record.
© AAPHD
33
+
Justice
Code of Professional Conduct:
4c. Justifiable criticism: Dr obliged to report instances of
gross or continual faulty treatment by other dentists.
Patients should be informed of their present oral
health status without disparaging comment about prior
services. Dr. issuing a public statement with respect to
the profession shall have a reasonable basis to believe
that they are true.
4d. Expert Testimony: Dr. may provide expert testimony
when that testimony is essential to a just and fair
disposition of a judicial or administrative action.
4e. Rebates and split fees: Dr shall not accept or tender
"rebates" or "split fees."
© AAPHD
34
+
Veracity
Code of Professional Conduct:
5a. Representation of Care: Dr. shall not represent the
care being rendered to their patients in a false or
misleading manner.
5b. Representation of fees: Dr. shall not represent the
fees being charged for providing care in a false or
misleading manner.
© AAPHD
35
+
Veracity
Code of Professional Conduct:
5c. Disclosure of conflicts of Interest: Dr. who presents
educational or scientific information in an article,
seminar or other program shall disclose any monetary or
other special interest with a company whose products are
promoted or endorsed in the presentation.
5d. Devices and Therapeutic Methods: Dr. shall be obliged to
prescribe, dispense, or promote only those devices,
drugs and other agents whose complete formulae are
available to the dental profession. Dentists shall have the
further obligation of not holding out as exclusive any
device, agent, method or technique if that representation
would be false or misleading in any material respect.
© AAPHD
36
Ethical Dilemmas
+

A situation where moral considerations can be found
on each of 2 opposing actions or two or more ethical
principles are in conflict.

Characteristics:
 Reasons on each side of the problem are weighty
 Neither side is obviously ‘right’
 If one acts on either side of the dilemma, one’s
actions will be desirable in some aspects, but
undesirable on others.
© AAPHD
37
Common Ethical Dilemmas
in Dental Practice
+

Dr-Patient issues on treatment or refusal to treat

Insurance and managed care issues, such as feesplitting, postdating treatment to secure third-party
payment

Interpersonal or personnel issues like assigning
appropriate level of tasks to employees, and the
obligation to report unethical or incompetent
behavior of a colleague,
© AAPHD
38
+
Is this a DPH ethical dilemma for clinic
director, Dr. Miguel Garcia?
EXCERPTS from, “Dentists Called Negligent in Death of Boy”
LA Times August 22, 1997|PETER M. WARREN & JANET WILSON | TIMES STAFF
WRITERS
SANTA ANA — Four-year-old Javier Villa, who died in a dentist's chair after having his
teeth drilled, was treated by dentists "who were incompetent and grossly negligent in
sedating or monitoring the boy," according to a dental expert cited in court documents.
Dr. Miguel Garcia, who supervised the dental clinic, also destroyed the child's dental
chart, altered records, withheld evidence and concealed the amount of drugs
(anesthesia) given the boy, according to witnesses quoted in a search warrant affidavit
filed in Municipal Court.
Javier, who stopped breathing in a dentist's chair and died at a hospital a few hours later
on Aug. 4, had been taken to the Megdal Dental Care office in Santa Ana to have six
cavities filled. He was given an oral sedative and an injection of painkiller.
(Expert witness Dr. Richard) Mungo also said improper positioning of the child on a
patient restraint board could have been a major factor in his death and that numerous
routine safety procedures were not followed.
© AAPHD
39
Class discussion: Analyzing
the case for Dr. Garcia
+

Did Dr. Garcia have an ethical dilemma?

Was the care provided to Javier Villa of an appropriate
standard of care?

Is Dr. Garcia a DPH professional?

Is Dr. Richard Mungo violating the ADA Code of
Professional Conduct in accusing Drs. Garcia and
Pham of negligence?
© AAPHD
40
+
Lecture 2
Application of Ethical
Issues On Dental Public
Health decision making
41
© AAPHD
Lecture Objective
+

Describe the principles and values
underlying dental public health and
compare to those for dental practitioners.

Describe and apply a framework for
analyzing the decisions and actions to be
made by dental public health professionals.
© AAPHD
42
Application of Ethical Issues
On Dental Public Health
decision making:
+

A framework for ethical reasoning, program selection,
and risk reduction,

Ethical issues related to Health Promotion

Ethical issues related to Disease Prevention
© AAPHD
43
Common ethical issues in
DPH practice?
+

Extent to which a DPH practitioner may ethically
infringe on individual’s rights to promote and improve
the health of the public?

Abuses of human subjects in research

Appropriate use of screening and broad vaccination
programs

Social and economic inequality and unequal access to
oral health services
© AAPHD
44
Common ethical issues in
DPH practice?
+

Advocating for cost-effective and appropriate use of
preventive measures throughout the life cycle
(primary, secondary, and tertiary prevention)

Interaction between treatment and the environment

Requirements to report abuses
populations during DPH activities

Development and implementation of midlevel
providers to improve the community’s access to
dental care.
© AAPHD
to
vulnerable
45
+
Principles of the Ethical
Practice of Public Health
1.
Protect and promote health: address
health risks
fundamental causes of
2.
Achieve community health while respecting the rights of
individuals
3.
Obtain input from community members
4.
Advocate and empower disenfranchised community members:
ensure basic resources for all
5.
Seek the information needed to implement effective policies and
programs
6.
Provide information and obtain the community’s consent for
implementation
Reference: Public Health Leadership Society, @2002
© AAPHD
46
American Public Health Association:
Principles of the Ethical Practice of
Public Health (con’t)
+
7.
Act on the information and the mandate given by the public.
8.
Incorporate a variety of approaches that respect diverse values,
beliefs, and cultures in the community
9.
Programs should enhance the physical and social environment.
10.
Protect confidentiality of information that can harm an individual
or community
11.
Ensure the professional competence of their employees.
12.
Engage in collaborations and affiliations in ways that build the
public’s trust and the institution’s effectiveness.
Reference: Public Health Leadership Society, @2002
© AAPHD
47
A Framework for Ethical
Reasoning for Health Promotion
Programs
+

What are the PH goals of the proposed program?

How effective is the program in achieving its stated goals?

What are the known or potential burdens of the program?

Can burdens be minimized?

Are there alternative approaches?

How fair is the program implementation in balancing
burdens/ risks and benefits?

Can benefits
balanced?
and
burdens
© AAPHD
be
more
appropriately
48
Can a program’s risk be reduced
to bring it in line ethically?
+

Determine what level or degree of risk is socially
acceptable to individuals and the community.

Who decides about the degree of risk that is appropriate,
and how should exposure to risk be distributed across an
affected population?

Consider, may parents select a level of risk for their
children, regardless of the impact on the child’s health?

Consider, does a DPH professional have a burden of proof
before they may initiate risk to a community in order to
demonstrate that the benefits will outweigh the dangers
and that the risk is rationally worth taking?
© AAPHD
49
+
Vending Machines Found in Most
Middle Schools
By Carolyn Colwell, HealthDay Reporter
Snacks, drinks sold not helping fight against childhood obesity, researcher notes
(Excerpted from article on October 6, 2008)
Three-quarters of middle schools have vending machines where snacks and
sugared drinks are sold, a new study finds. The research demonstrates that
there are vending machines in most middle schools, and "that those vending
machines don't always have the healthiest choices," said study author Amy
Virus, a registered dietitian with the Center for Obesity Research and
Education at Temple University in Philadelphia.
The results come from a nationwide sample of 42 middle schools, and
researchers discovered that most of these vending machines offer food and
beverage choices that contain as much as 320 calories an item,Virus said.
The next step will be to eliminate 100 percent fruit juice from these schools'
vending machines, change snack and desert foods to 200 calories or less,
and change chips to reduced fat or baked snacks. More water will be placed
in the machines if recommendations are followed.
© AAPHD
50
Class Discussion:
Advising School Board on Vending
Machines
+

You, as the local Dental Director, have been asked to advise
the school board on whether to remove high sugar drinks.

You consider what is the effectiveness of the program.

Is this is an ethical dilemma and if so, what principles are in
conflict?

What is the DPH professional’s role and responsibility in
this situation?

How do you justify the decision using the ethical principles
of Public Health Leadership Society in your response?
© AAPHD
51
+ Activity:
Incorporating ethical principles
into DPH decision making

Take a recent DPH issue, or one of these examples (a
Medicaid parent giving a toddler a milk bottle when the
child goes to bed at night, or a parent deciding to not allow
a child to participate in a school sealant program), how are
ethical dimensions of public health policy identified and
debated?

Consider the scope of ethical issues raised within the 4
general categories of public health: health promotion and
disease prevention, risk reduction, epidemiological and
other forms of public health research, and structural and
socioeconomic disparities in health status. How does this
situation fit?
© AAPHD
52
+
Lecture 3
Application of Ethical Reasoning
on Dental Public Health decision
making
53
© AAPHD
Lecture Objective
+

Describe and apply a framework for
analyzing the decisions and actions to be
made by dental public health professionals.
© AAPHD
54
Lecture 3:
+
Application of Ethical Reasoning
on Dental Public Health decision making:

Disease Prevention

Considerations in human subject research

Collection and use of epidemiologic data & Population
surveillance
© AAPHD
55
DPH examples of ethical issues:
Promotion of population health
+

DPH’s responsibility to encourage individual’s,
family, or school’s healthy lifestyle and healthy
behaviors


Create an environment that is conducive for an
individual to readily exercise his health-related
responsibility
Provide incentives or develop educational programs
that promote good health but respect cultural traditions.
© AAPHD
56
Justifying PH programs that
conflict with individual liberty
+





Is the effectiveness of the PH program HIGH?
Proportionality: do the probable benefits of the
program outweigh the infringed general moral
considerations?
Is the program critical to achieve the PH goal?
Does the Program offer the least infringement of
personal liberties among the alternatives?
If yes, can you justify this program is appropriate?
© AAPHD
57
Disease Prevention A Tale of two
Cities: A Case for Fluoridation
+

Pinellas
County,
Florida:
Community
water
fluoridation since 2004, decides to halt water
fluoridation on October 4, 2011.

Hillsborough County, Florida: Community goes ahead
to raise the money to implement already approved
water fluoridation
© AAPHD
58
+
Disease Prevention A Case for
Fluoridation: Pinellas County
© AAPHD
59
+
Fluoride
IMPORTANT NOTICE for all Pinellas County Utilities Water Customers
The Pinellas County Board of County Commissioners voted on October 4, 2011, to
discontinue the practice of adding additional fluoride to drinking water supplied by
Pinellas County Utilities.
The addition of fluoride was discontinued as of December 31, 2011.
Please consult your dentist, pediatrician or family doctor if you have questions
regarding proper dental care.
Why is water fluoridation being discontinued?
The discontinuation of water fluoridation is the result of a decision by the Pinellas
County Board of County Commissioners on October 4, 2011.
When will fluoridation officially stop?
The addition of fluoride to the water supply was discontinued as of December 31,
2011.
Will my utility bill be reduced as a result of the discontinuance of fluoride?
Because of the minimal cost of fluoridation per customer, utility bills were not
increased when fluoride was first added and there will be no adjustment to utility
bills when fluoridation is discontinued. The annual cost of water fluoridation was less
than 30 cents per customer.

Try to get the actual picture of the website!!
© AAPHD
60
Pinellas County Commission votes to
stop putting fluoride in water supply
+
By David DeCamp Tampa Bay Times Staff Writer
In Print: Wednesday, October 5, 2011

CLEARWATER — Pinellas County will stop adding fluoride to its
drinking water, ending a cavity-fighting effort that riled critics of
Big Brother government despite decades of advocacy by dental
and medical experts.
After three hours of polarizing debate, the County Commission
voted 4-3 Tuesday to halt fluoridation to about 700,000 residents of
the county and most Pinellas cities.
The vote came despite pleas from a dozen dentists and health
officials who told commissioners that fluoride reduces dental
illness while lowering costs to the county for dental care for the
needy.
© AAPHD
61
+
Disease Prevention A Case for
Fluoridation: Hillsborough County
City Officials unanimously approved spending
$300,000 raised to implement the plan
© AAPHD
62
+
Fluoridated Water and Infants
from, The COMMUNICATOR Keeping You Informed
About County Government August 2007

You may have heard or read recently about an American Dental Association
statement regarding infants and fluoridated water. How do utilities - like
Hillsborough County Water Resource Services - decide whether to pass along
such information to customers?

As a public utility which provides high-quality drinking water to more than
350,000 people, Water Resource Services receives numerous advisories,
statements, position papers, opinions and articles from a wide variety of
sources. Our staff carefully evaluates each new development in the industry.
Medical issues in particular can be extremely complex and confusing, and
difficult to put into context by anyone other than medical professionals. That is
why, in such matters, we rely on medical experts - in particular, the Hillsborough
County Health Department - to evaluate the validity of the material and
determine what message should be relayed to the public. Utilities are not
allowed to make such judgment calls themselves. To do so would violate
procedures, protocol and laws established to safeguard our customers.
© AAPHD
63
Fluoridated Water and Infants
+
from, The COMMUNICATOR Keeping You Informed
About County Government August 2007

The ADA is among dozens of major health organizations that endorse
community fluoridation to prevent tooth decay. The ADA's concern, based on
a study done by the National Research Council, is that infants who receive
fluoride above optimal amounts may be susceptible to fluorosis, a condition
that damages tooth enamel. The optimal fluoride level in drinking water is 0.7
to 1.2 parts per million. Water Resource Services supplies 0.8 parts per
million of fluoride in its drinking water. Further, both the ADA and the
National Research Council indicate that additional research is needed.

The health and safety of our customers is paramount. This is a responsibility
we take very seriously. We trust in the judgment of the qualified experts who
advise us on medical issues related to our drinking water. When they deem
an advisory or public notification necessary on any health-related issue, you
can be assured that we will use every means available to share this
information with you.
© AAPHD
64
+
How do the two examples demonstrate
the ethical responsibilities of a DPH
professional?
© AAPHD
65
+
Informed Consent
 Definition:
the process by which a DPH practitioner fully
informs a patient about his/her treatment or program
choices, including no action.
 Characteristics:




Voluntary and fully informed
Includes the nature of the problem and proposed action/ inaction
Reasonable alternatives to the proposed intervention or program
Relevant risks, benefits, and uncertainties associated with each
alternative
© AAPHD
66
+
Informed Consent
Class Discussion:
1.
Which of the Principles of the PH Leadership Society relate
to informed consent?
2.
Was informed consent provided by the subjects in the
Vipeholm study? If not, how do you suggest that the study
could have been improved?
3.
Are there extraneous circumstances when informed
consent is not necessary?
© AAPHD
67
+
Considerations of Human Subjects
in Research: Vipeholm study
Background: In 1954 a study was begun in Lund, Sweden of
the association between diet and dental caries. It was carried
out at the Vipeholm Hospital, that housed individuals with
mental handicaps.
The study was proposed by the Medical Board, at the request
of the Swedish Government, that was considering the
implementation of an expensive Public Dental Service.
Then current literature on carbohydrate intake and dental
caries was not conclusive, no animal models were available
for testing the association, and some evidence was now
available that fluoride in water could have a protective effect.
© AAPHD
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Considerations of Human Subjects
in Research: Vipeholm study
In the Carbohydrate Study I, extreme conditions were applied:
sugar was given in one of three forms – in solution with only
slight retentive properties, or in sticky form at meals (bread)
or between meals (5-6 caramels each, 4 times daily).
Results generally showed that control of level of sugar, or if
only given during meals, caries incidence was low. Sugar
given in sticky form between meals increased caries activity
greatly.
A group of about 20-30% of subjects did not increase their
caries incidence.
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Considerations of Human Subjects
in Research: Vipeholm study
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Class Discussion considering the PHLS principles:

Are there ethical concerns about the fact that this
study was conducted on subjects who were mentally
handicapped?

What factors might explain the decision of the Medical
Board to approve this study?

Would such a study be conducted today? Why or Why
not?
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Collection and use of epidemiologic
data & Population surveillance
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
Do the use of public health laws and regulations have
an explicit moral purpose (to promote and protect the
lives of citizens) that justify the use of police power of
the state?

Are the risk and benefits of data collection and
program benefit shared equally?

Does social justice demand more than a fair
distribution of resources in extreme public health
emergencies?
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Prevention or Control of Oral
and Pharyngeal Cancers

About 30,000 Americans, mainly squamous cell carcinomas are
diagnosed annually, and about 8000 people die of these malignancies.

Oral and pharyngeal cancers are the 4th (A-A men, 7th (white men), and
14th (women) most common cancers.

Tobacco use and alcohol consumption are risk factors that together
account for 90% of all oral cancers.

Often they are diagnosed at late stages and treated by disfiguring and
costly methods.

Overall relative 5-year survival rates are about 50%, and mortality is
nearly twice as high among some minorities (especially AfricanAmerican men) as among whites.
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Counseling on
low incidence diseases
© AAPHD
Balancing collection of epidemiologic
data and implementing early detection
programs for Oral Cancer
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 It
was determined there is insufficient evidence to
determine the effectiveness of population-based
interventions for early detection of pre-cancers and
cancers in improving morbidity, mortality, or quality of
life.
 What
is the ethical responsibility of the DPH
professional in balancing the implementation of data
collection efforts, diagnosis programs, and treatment
programs?
Am J Prev Med 2002;23(1S)
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DPH ethical reasoning?

Should studies of the effectiveness of community based
interventions be deferred until clinical effectiveness in
reducing morbidity and mortality has been established?

What roles should various professionals play in early detection
of oral and pharyngeal cancers?

How should effort and other resources be allocated among
strategies designed primarily to prevent these cancers (e.g.,
tobacco use prevention) versus strategies aimed at early
detection?

To what extent do early detection efforts reinforce messages
about reducing tobacco and alcohol use?
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Lecture 4
Case
Code of Conduct
76
© AAPHD
Lecture Objectives
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
Recognize the similarities and differences in the mission of
dental practitioners versus the dental public health
practitioner and how to respond to common ethical issues
facing each.

Describe the principles and values underlying dental public
health and compare to those for dental practitioners.

Describe and apply a framework for analyzing the decisions
and actions to be made by dental public health
professionals.
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A Case of Elder Abuse?
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
Mrs. S. is an 85 year old widowed woman who lives with her daughter and 3
teenage grandchildren in a house she has owned for over 50 years. She is a
long-standing patient of Dr. D. at this FQHC and is well known to Dr. D. and
the office staff.

She arrived with her daughter late to a rescheduled appointment appearing
unkempt, disheveled, with a slight urine odor. While helping her mother into
the dental chair, the daughter informed the dentist that her boyfriend
recently moved in with her family.

Mrs. S. was unable to answer many of the standard history questions,
appearing confused and anxious, looking to her daughter to answer
questions. Examination of her mouth showed she was not practicing daily
oral hygiene and had angular cheilosis. Radiographic exam revealed
displacement of her lower jaw. When asked if something happened to her
mouth, Mrs. S. became agitated, distressed, and tearful. Her daughter stated
that the family had been under a lot of stress lately with money worries,
problems with the teenagers and her mother needing more and more help.
© AAPHD
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Ethics Case, continued
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
When the daughter left the room, Mrs. S. revealed that she didn’t like her
daughter’s boyfriend living in the house so she was spending most of her
days in her bedroom since she can’t “get to the bathroom in time.” She stated
that the boyfriend gets really angry when she has an “accident” and a few
weeks ago he “slapped her across the face” when she soiled the living room
couch.

When asked if she would like some help with this problem, she repeatedly
asked Dr. D. not to say anything to her daughter as she was enough of a
burden to her daughter already and didn’t want to cause more problems,
stating; “it was my fault, I was watching my favorite show on television and I
didn’t go to the bathroom when I should have.”

At the end of the day Dr. D. meets with you, the FQHC director, to discuss the
day’s patients. Dr. D. mentions Mrs. S. and the situation with her daughter, her
boyfriend, and the possible signs and symptoms of neglect. You ask Dr. D. if it
appears that the daughter and her boyfriend are abusing Mrs. S.
© AAPHD
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Ethics Case Continued
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Ethical Considerations for the dental practitioner

Confidentiality vs. nonmaleficence

Conflict of interest vs. beneficence:

Paternalism:
Ethical Consideration for the DPH Professional

Address the causes of disease/disability and aim to prevent adverse outcomes vs.
respect the rights of individuals in the community.

Advocate for disenfranchised members of the community vs. implement effective
programs that protect health.

Act in a timely manner vs. protect the confidentiality of information that can bring
harm to an individual.

Ensure the professional competence of employees.
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Ethical Codes of Conduct:
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
An intent to ensure better future conduct of people in
the profession.

Establish the moral credibility of profession and
provide principles to guide decisions by professional
faced with common dilemmas.

Provide a profession with a moral compass and
establish its ideals.
© AAPHD
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The Public Health Professional’s
Oath
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
DRAFT – 4/25/03 – DRAFT

As a public health professional, I hold sacred my duty
to protect and promote the health of the public. I
believe that working for the public’s health is more
than a job, it is a calling to public service. Success in
this calling requires integrity, clarity of purpose and,
above all, the trust of the public. Whenever threats to
trust in my profession arise, I will counter them with
bold actions and clear statements of my professional
ethical responsibilities.

I do hereby swear and affirm to my colleagues and to
the public I serve that I commit myself to the following
professional obligations. …………….
http://www.apha.org/codeofethics/ethicsbrochure.pdf
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How to consider a response for a
seemingly unethical situation
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
Identify the unethical behavior. Is it personal or
institutional behavior?

Is the behavior unethical or illegal?

Is it life-threatening to one or more individuals, or
does it contribute to chronic mistreatment of a group
of individuals?

What is your responsibility in DPH?
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Whistleblowing
 Definition:
The responsibility of an individual to report
suspected misconduct; exposure of fraud and abuse by
an employee.
 Whistleblower:
an informant who exposes wrongdoing
within an organization in the hopes of stopping it.
 Who
bears the responsibility to report?
 Rules
for reporting suspected misconduct
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Whistle blowing
 Protected
under federal law, the False Claims Act
(1863, revised 1986), created to combat fraud by
suppliers to the federal government during the Civil
War.
 Provides
whistle-blowers with a percentage of the
money recovered or damages won by the government
in fraud cases.
 Protects
whistle-blowers from wrongful dismissal, or
retaliation.
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Rules for reporting suspected
misconduct
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
Consider alternative explanations (difficult for students to
weigh alternatives – who to get help from)

Ask questions, before making ‘charges’

Gather documentation

Separate personal from professional concerns

Assess your goals (what do you hope to accomplish?)

Seek advice (and listen to it)

Establish the correct process

Cultivate patience
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Class end project
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Create a Code of Ethics for
Dental Public Health
“Imagine that you are the Director of the Public Health Dentistry
department for your city.You are newly come to the position and
want to set a positive environment for the actions that your group of
dentists, dental hygienists, and health educators will take in the
community. Historically, the PH Dentistry group works actively to
improve the oral health of this lower SES community, including with
the K-12 public schools, the senior centers, and the WIC centers.
This morning you are welcoming the group to the Strategic Planning Retreat and your first
task is to set them to work on creating a Code of Ethics that can be shared with the
community to demonstrate how your values and principles will positively engage the
community in the actions that the PH Dentistry professionals will take this year.”
Each group of 4-6 people should work on creating your code of ethics for 20 minutes then
report back to the larger class what each group develops. A consolidated Code of Ethics
can be agreed upon, if desired.
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