Ethics and morals: reflections of public health service dentists

Abstract

This study aimed to analyze the ethical dimension experienced by dentists in the professional practice of a city in Rio Grande do Sul, Brazil, in order to contribute to the improvement of the work of these professionals. This is a qualitative study with content analysis. A semi-structured interview was used to collect data and eight dentist participated in the sample. The results show that there are flaws in the understanding of the Código de Ética Odontológico (Dentistry Code of Ethics) by most dentists, and little knowledge of professional ethics, leading to a lack of reflections on their daily practice. The study suggests that ethical flaws may be related to the content taught in the training of professionals in which the healing practice was predominant with focus on the technical aspects and little emphasis on knowledge aimed at humanization, prevention and health promotion.

Ethics; Dentistry; Public sector

Resumo

Este trabalho teve como objetivo analisar a dimensão ética vivenciada por dentistas na prática profissional de uma cidade do Rio Grande do Sul, Brasil, a fim de contribuir para aprimorar o trabalho desse profissional. O estudo é de cunho qualitativo com análise de conteúdo. Foi utilizada entrevista semiestruturada para coletar dados, e participaram da amostra oito dentistas. Os resultados mostram que há problemas no entendimento do Código de Ética Odontológica por parte da maioria dos dentistas participantes, e pouco conhecimento de ética profissional, o que leva à falta de reflexões sobre a prática diária. O estudo sugere que falhas éticas podem ter relação com o conteúdo ministrado na graduação dos profissionais, na qual predominava a prática curativa com foco nas questões técnicas de ensino e pouca ênfase em humanização, prevenção e promoção de saúde.

Ética; Odontologia; Setor público

Resumen

Este trabajo tuvo como objetivo analizar la dimensión ética vivenciada por los odontólogos en la práctica profesional de una ciudad de Rio Grande do Sul, Brasil, con el fin de contribuir a mejorar el trabajo de este profesional. El estudio es de cuño cualitativo con análisis de contenido. Se utilizó la entrevista semiestructurada para la recolección de datos, y participaron de la muestra ocho odontólogos. Los resultados muestran que hay problemas en la comprensión del Código de Ética Odontológico por parte de la mayoría de los odontólogos del estudio, y poco conocimiento de ética profesional, lo que conduce a la falta de reflexiones sobre la práctica diaria. El estudio sugiere que las fallas éticas pueden tener relación con el contenido suministrado en la carrera de grado de los profesionales, en la que predominaba la práctica curativa con foco en las cuestiones técnicas de enseñanza y poco énfasis en la humanización, prevención y promoción de la salud.

Ética; Odontología; Sector público

Ethics is the branch of philosophy that studies morality, a kind of “science” of morality, the reflection on what is right and wrong. These are norms for human social co-operation that seek to answer the question “how should I behave?” ¹. Its purpose is to clarify and systematize the bases of moral fact and to determine the guidelines and abstract principles of morality ².

The Código de Ética Odontológica - CEO (Dentistry Code of Ethics) ³, is the normative reference for dentists, whose norms have the pedagogical sense of avoiding the performance of unethical acts, actions that generate damages for the patient and the professional ². The latter must be aware that in addition of the techniques learned during his academic training, they must also learn to deal with the body and mind of the human being ¹,⁴.

Ideally, professional ethics should be part of the curriculum of dentistry, being essential for the professional to be able to identify the individuality of each person and the singularity of each situation ⁵, however much they have been ignored for so long. It is evident that the difficulty of dentists in resolving ethical conflicts is accentuated by the fragmentation of dentistry in technical specialties, which makes it difficult to perceive the integrality of the human being. Models of cognitive learning (knowledge) and psycho-motor (skills) based on surgical technique and teeth repair predominate, rather than the reflection on daily ethical problems of the professional ⁶-⁸.

Currently, dentistry is undergoing changes and some studies show that more attention has been given to a new form of treatment, in which not only curative but also preventive care is done ⁹. This is due to changes in the curriculum of most colleges, which aim to emphasize knowledge aimed at humanization, prevention and the promotion of health ⁷.

Today, health professionals speak more openly to patients about their health and treatment options, and they feel more comfortable asking questions and discussing concerns. This change underscores the patient’s autonomy, that is, their right to participate in decisions regarding their health ¹⁰. This has helped dentists to meet their expectations, making dentistry a multidisciplinary profession in which patients are treated with commitment and justice, based on standards and the CEO ⁶.

There are some challenges in relation to the ethical dimension in primary health care. Among the main ones are the lack of financial incentives, high patient demand, lack of strategic planning, poor infrastructure, and little or no interaction among team members ⁹. Some studies still point to the need to include care management technologies in practice in both the private and public sectors, in order to improve the ethical ⁷.

It is known that ethical professionals are well-regarded and are good examples for students of dentistry ⁶,¹¹,¹². In addition, the literature records that undergraduate ethics teaching is changing ¹³, but it is still not clear how the dentist perceives the ethical dimension that he experiences in the public service, considering the CEO.

The purpose of the present study was to analyze this dimension in the context of the professional practice of dentists of the public health service of a city of Rio Grande do Sul, and its relationship with colleagues and users, to verify the working conditions in the Sistema Único de Saúde – SUS (Unified Health System).

Methods

This is a descriptive exploratory study with a qualitative approach. It answered very particular questions in the scope of the ethics perceived by the dentists, and that could hardly be translated into numbers and quantitative indicators ¹⁴.

Data were collected in September 2017, and the sample included eight dentists who worked in the basic health units of a city of Rio Grande do Sul. They were randomly selected, both sexes, between 34 and 64 years of age, and with training time between 10 and 40 years. The number of participants was defined during the survey, and the sample was considered sufficient when it was noticed that the statements started to repeat, that is, there was a saturation of the data ¹⁴.

The purpose and the importance of the study were explained, and anonymity and confidentiality were ensured in the collection of information and presentation of the results, after the signature of the consent term. In addition, a semi-structured interview script was used by a previously trained person, from a pilot interview to test the understanding of the issues.

The interviews were then recorded separately and the responses faithfully transcribed to a form. The subjects were questioned about their perceptions of the ethical condition established in their relationships with colleagues, users and working conditions. The research data were examined through the content analysis proposed by Bardin ¹⁵, and in the initial phase was read carefully in order to revive the first impressions of the interviewer.

After that, in the coding and classification stage, they were regrouped, analyzed and categorized. This involved re-reading the transcriptions, comparisons, and connections until no further categories were identified and the data were saturated. The validity and reliability of this analysis were obtained by rigorous procedures throughout the research and validated externally by the supervision of another researcher ¹⁶,¹⁷.

Results

Respondents were identified with code names represented by the letter “E” and numbered according to the interview order. Table 1 shows that most of them were females, with a mean age of 44 years and an average training time of 20 years.

Table 1
Characterization of subjects

Subject	Sex	Age	Time of training/years
E1	F	48	26
E2	F	57	32
E3	F	37	13
E4	F	64	40
E5	M	35	11
E6	M	45	23
E7	F	38	15
E8	F	34	10

Four categories of ethical questioning were established, the first one related to problems in the relationship between the dentist and the user, the second to difficulties among colleagues, the third concerning obstacles in the relationship of the professional with the management, and the fourth dealing with the ethical perception of the subjects.

Ethical issues in the dentist’s relationship with the user

Patient enticement

Referring patients to other colleagues and universities came up in the interviews as a common practice among the interviewees: “We forward them to the university, to schools that make prostheses” (E2), or even to offer their own business card was something common in the public service of health: “If the patient asks, then I say that I am an orthodontist and give a little card, right? But there is no way to make a budget here in the post, there is no way to entice anything, right? This is unethical, so normally, when they ask, I give my card “ (E8).

However, treating patients from the public service in the private practice was seen as an unpleasant experience, because there was a case where the person sought care outside of business hours: “I took my patient to the office; only that this was the only patient in my life who woke me up in the middle of the night” (E1).

According to the interviewees, some colleagues referred patients from the units to the private practice, with the justification that there was not enough material in the public system for a particular procedure, and there was also a suspicion that they were taking materials from the unit: “We see colleagues saying that they do not have material just as an excuse to send that patient to their office ... things like: disappearing from the office, right? So somebody is taking it away, right? Taking material to their office” (E4).

Some dentists did not have a private practice and only worked in the SUS, or did not think it necessary for the patient to be cared for in the private service, because they believed to offer the same type of service and care in both places: “Because the work that I would do in the office is the work I do in the public service and there was no reason to refer them, right?” (E4).

Users complain about other dentists

Dentists reported that users often complain about treatments performed by other colleagues: “I try to explain to them that, from the moment they sit on the chair and will have the procedure with me, we’ll start from scratch, what happened before is not important” (E5). They also try to show that the colleague tried to do his best: “Sometimes the colleague does their best and then they come after me and complain about the colleague, and then we have to explain to the patient that this is normal and never talks about a colleague to a patient” (E4).

The following statement reveals the questioning that the patient did not understand the procedure proposed by the colleague: “Once a patient came saying very bad things about a colleague: ‘that I would not believe what the colleague had done, that the colleague had made a horrible thing ... that he had left a cotton ball inside his tooth’” (E3). Another dentist offered the client a different treatment from the one offered by a colleague and reported that, afterwards, the patient stated that they would not return to the previous dentist: “Will you congratulate me today because you have saved two of my teeth for me? I ask her, ‘So, did you go back to the dentist to get the new prosthesis?’ ‘No, I will not go back there again [laughs]’” (E1).

Collective and individual actions to promote health

Providing individual hygiene guidelines is a common practice among dentists. Some assign the first appointment to get know the patient better and to solve all doubts. In the following appointments, they try to carry out the planned procedures, but whenever necessary, they return attention to this type of health action. Others put these actions into practice at each visit and when treating children, usually accompanied by the person in charge, take advantage of evidence of prevention and health education: “The mother comes along, then I take this appointment, I sometimes take the opportunity to talk to the mother; I try to find a way to make the mother helpful in the office”. (E8).

Although few of them think of actions in groups, many claim to take advantage of vaccination campaigns to promote oral health. In addition, most of them do the education and prevention work in schools through the Programa Saúde na Escola - PSE (Health in the School Program), which has partnerships with trainees assigned by the universities in the municipality:

“In schools, I participate in the PSE project. Then I go to the schools, offer lectures, supervised brushing, apply fluoride and provide the brushes. The PSE is the school health program that now also includes the area of dentistry” (E3);

“We use vaccination campaigns to have an activity, kind of a mega-event because in the vaccination campaigns, everyone comes” (E8).

Despite this, the effectiveness of these practices is questioned: “So I believe that I work on prevention in baby steps, I do the work of the hummingbird that goes there and ... But I think it is often more efficient as a collective action ... They’re going to kill me, but [laughter] when we do a collective action how many you can you reach that will keep doing... Now the patient who goes into the office, you teach them and they understand, they will not forget it again, right?” (E1).

Ethical difficulties in the relationship among colleagues

Some dentists reported having worked in teams where there was no good relationship or respect. Others even witnessed professionals recording other colleagues on video: “Others even witnessed professionals recording other colleagues on video: “I have worked in worse teams, right, that has colleagues filming colleagues”” (E8).

Ethical constraints in the relationship of the dentist with the management

One interviewee said that he had a bad relationship with the unit’s coordination because they did not receive support in activities that could improve the quality of care. Others complained about the lack of space and environmental conditions: “Let’s talk about the physical part: the office is a bit small, it could be larger” (E4); “I do not have a curtain and the sunlight keeps bothering me, the sunlight sometimes gives me a headache” (E8).

The lack of air-conditioning is another point that interferes with the well-being of both the patient and the professional “The main thing is the lack of air conditioning, in the summer you can not get in! You can not go in there ” (E3). The smell of sewage that reaches the treatment room and the presence of mold were also mentioned: “(...) a strong smell of sewage, the smell of mold; all the times the coordinator has already requested, has already been requested, but nothing has been done” (E3).

Finally, most dentists considered as positive the monthly training performed by the city administration: “We are always doing training, we have monthly meetings, where they offer training in various areas” (E6).

Perception on ethics

Dentistry Code of Ethics (CEO)

The dentists in the study define ethics based on a set of norms and behaviors that govern the profession and serve for the proper functioning of the unit and the accomplishment of the work: “Both in relation to the place where we work, to the use of the material, and also in relation to colleagues, I think we should be ethical, as well as in relation to the patient” (E4). Ethics also appears concerning the respect for the colleague, in the good relationship and consideration for their work:

“Respect the work of the colleague, do not get defective in the work of the colleague” (E3);

“Very important for us to be able to provide a good service” (E6).

Ethical principles

Issues have arisen about beneficence, acting for the benefit of the patient: “To see in the other one the same people, right, like a relative. So that is something we should be well aware of, for me this is ethics” (E4). Respect for autonomy has been related to transmitting confidence to the patient and the need for the professional to let them know the details of their health condition so that they can understand their situation: “I always tell patients this: that they have to learn how to take care of their health because patients normally give themselves away to professionals” (E4).

Discussion

The results highlight important points that suggest flaws in the professional conduct of dentists, according to the CEO. The results show that the dentist holds relative knowledge of what is set out in the CEO, and some knowledge of professional ethics, but does not make deeper reflections on the subject in his day to day practice. After all, the notion of ethics needs to be expanded not only within the professional scope but encoded in obligations and rights for an ethics of the human race ¹⁸.

In the present study, the theoretical framework followed the conduct of the subjects in the light of the CEO ³ standards, which condemn the enticement of patients, that is, one can not attract or divert, by any means, a patient from a public or private institution to a private clinic. However, the statements tell us that, even though it is an unethical procedure, dentists still practice this illegality. It is clear, therefore, that there are discrepancies between the knowledge of the CEO and the practice of dentistry.

From the study, it is noted that the work process of the dentist is the same in the private and public service. The CEO ³ considers the fundamental duty of the dentist to promote collective health in the performance of his duties, but the professional profile still remains more focused on curative actions. In most cases, preventive and/or collective actions have been restricted to individual care in offices or schools, and are insufficient and based on vertical policies, such as the Health in School Program. In addition, there was some resistance to these activities - some professionals even questioned its effectiveness.

It was evidenced the maintenance of traditional practices, such as individual curative care and preventive work in schools, that is, work process that privileges characteristics of hegemonic practice ¹⁹. This can be explained by the time of training of the dentist, in average 20 years, indicating an educational process still based only on curative practice and little focused on collective health.

Ordinance 2,436/2017 ²⁰ approved the Política Nacional de Atenção Básica (National Policy of Primary Care) and, when dealing with the dentist’s assignments in the Family Health team, defined that clinical procedures should integrate collective actions and multi-professional teams. It is noteworthy that, in the present study, no dentist reported team activities.

Some of the interviewees sought to be impartial in their relationship with colleagues - when, for example, a professional received the patient’s complaint about the procedures performed by another dentist. The professional misconduct is often surrounded by walls of silence, especially when the user is not aware of the problem, or when the fault is perceived by the person and the situation is circumvented by excuses that justify the action performed by another colleague, in a sort of “corporate loyalty” with other professionals ⁷.

However, in the sample one of the dentists offered a different treatment for the mis-diagnosis of a colleague, emphasizing the better quality of their own intervention, which constitutes an ethical infraction, since criticizing the procedures of other colleagues for patients under their care is a behavior forbidden by the code of professional ethics ³.

The lack of communication of the dentist was one of the aspects evidenced in the present study, considering that the treatment was not explained to the user. This disrespects the ethical principle of autonomy, preventing the individual from understanding what is being done in their teeth and collaborating with the evolution of the treatment. Considering the general perception of the patient, their personality, problems, and particular desires is fundamental for good communication and the success of dental care ²¹.

It is also possible to recognize a lack of care management, due to the valorization of hard technology at the expense of the humanization of care. That is, with more modern equipment, the professional tends to increased specialization and, thus, to move away from the broader spheres of the health process ⁷,²². This implies the removal of the dentist from the subjective dimension that every health practice presupposes, that is, from the use of light technologies, from the relation of the health professional to the user in the production of the act of caring ²².

Another relevant issue concerns the unhealthy work conditions reported by the participants: excessive sunlight and heat, the presence of mold and the smell of sewage. Dentists are unaware of or ignore the fundamental right of the professional, as defined by the CEO ³, to refuse to engage in public or private practice under unworthy, unsafe or unhealthy working conditions. Different considerations in the literature indicate that transformations in the health area depend not only on the manager’s attitudes but also on the involvement and commitment of the dentists ²,⁷.

Many of the ethical problems found in the present study relate to infractions described by the CEO, which confirms the poor moral and ethics of duties acquired by many students during academic training, insufficient to solve problems that arise in professional practice ⁷.

The challenge to better understand and apply ethics in dentistry lies in the training of the professional, and in choosing the adequate methodology of teaching ethics to deal with the current issues of society and to recognize the complex biopsychosocial reality of individuals. The greater dissemination of the CEO is also of paramount importance to clarify the profession of the dentist and, for further understanding, it is still suggested the elaboration of a commented version of the CEO.

Among the limitations of this study is the possibility that dentists have taken advantage of the interview opportunity to express their anguish, which may have increased the amount and intensity of negative emotions. The qualitative approach was adequate to the study because it provided more explanations about the subjective aspects of the actors involved.

Final considerations

The importance of ethics in working life is recognized by the interviewees, but not fully implemented. The professionals have the notion of the ethics of duties and moral acquired in their professional training, but they still find difficulties to solve problems of the daily practice. This may be related to the training of professionals in dentistry courses that focus more on curative and individual processes, in a context of great technicalization, without giving so much importance to ethical conducts and collective prevention actions.

There is evident lack of preparation of the professionals regarding the ethical conduct, which leads them to ethical conflicts in the daily life of the profession. Therefore, the study of the code of ethics becomes essential for more efficient inter-relationships and humanization of care, as well as better orienting professionals on their rights, duties and working conditions.

The results of this study may be similar in several Brazilian municipalities. Considering the predominance of the curative model in the area of dentistry, more studies on ethical perceptions should be carried out to verify the effectiveness, efficiency, and impact of new dentistry curricula. In addition, further research in the field of bioethics is needed that relates professional practice and training of the dentist in order to reduce unethical behavior.

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Publication Dates

• Publication in this collection
  01 July 2019
• Date of issue
  Apr-Jun 2019

History

• Received
  8 Apr 2018
• Reviewed
  25 Oct 2018
• Accepted
  26 Oct 2018