Ethical practice during the COVID-19 pandemic

Q: As a practitioner, I have had to balance many conflicting demands, agendas, and needs, both personal and professional, during the COVID-19 pandemic. Keeping current with guidance at the local, state, and national level is challenging, and I am wondering what my ethical responsibilities are during this difficult time.

A: Although the American Dental Association Principles of Ethics and Code of Professional Conduct (ADA Code) is a helpful guide,¹ you also must be mindful of your state’s and the national government’s emergency health powers acts. Under such powers, you may be required to surrender equipment or supplies, practice social distancing, or disclose identifiable patient information.² Under such emergency circumstances, therefore, your ethical obligations may change.

The ADA Code directs dentists to “have the benefit of the patient as their primary goal.”¹ This might cause you to wonder how you can ethically defer elective procedures or even temporarily suspend your practice operations. The principles of Nonmaleficence (“do no harm”), Beneficence (“do good”), and Justice (“fairness”) actually all support these measures, however. 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.”¹

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.”³

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.¹ There may be a temptation to conserve a limited supply of PPE by cutting corners, but stretching the supply rather than adhering strictly to the guidelines increases the risk of transmission to our patients, our staff members, and ourselves and further strains the already overburdened health care system. The principle Beneficence makes it clear that our “primary obligation is service to the patient and the public-at-large.”¹ If you run out of PPE, you have an obligation to not continue business as usual.

Limiting practice, however, does raise some concerns about the principle of Justice that bear consideration under these unusual circumstances. 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.”¹ 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.”¹

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. This may be motivated in part by a sense of avoiding harm to employees who would have their income reduced if the practice is not able to meet payroll for a period. The greater risk, however, may be to the employees’ health and the health of the broader community. We are all human, and we cannot help but consider the financial strain on everyone in the 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)¹ 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. The social contract of the profession depends on dentists’ “commitment to society that its members will adhere to high ethical standards of conduct.”¹

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.